Certificate of Records Destruction

ARCHIVES AND RECORDS MANAGEMENT
1
of
1
Revised 08/2013
An Equal Opportunity Employer
As authorized under ARS §41-151.19, ...A report of records destruction that includes a list of all records disposed of shall be filed at least annually 
with the state library on a form prescribed by the state library.
Failure to comply with these procedures is a violation of ARS §41-151.19.
Public Body
City of El Mirage
Division
ARIZONA STATE
LIBRARY, ARCHIVES AND PUBLIC RECORDS
A DIVISION OF THE ARIZONA SECRETARY OF STATE
Joan Clark, State Librarian & Director
Page
CERTIFICATE OF RECORDS DESTRUCTION
# of Files, Boxes, 
Reels; Electronic 
File Size
Hydrant Records-All Others (Flow tests)
GS 1024
10373
7/29/2013
9/29/2017
Paper
0.25
Department
Fire Department
Office/Unit
Record Series Title as Stated on Approved Schedule
Schedule Number 
or Date
Item #
Records Start 
Date
Records End 
Date
Format:
 Paper, Digital, 
Microfilm
0.50
Inspection Summary Reports
GS 1024
10376
8/11/2003
Paper
Title: Records Officer or Designee (type or print):
Phone :
Name (type or print):
Chris Richardson, Interim Fire Chief
Charlotte Confer, Records Officer Fire Dept
623-251-3501
RECORDS MANAGEMENT CENTER
1919 West Jefferson Street  •  Phoenix, Arizona  85009  •  Home Page:  http://www.azlibrary.gov/records
Phone:  (602) 926-3815  •  FAX:  (602) 256-2838  •  E-Mail:  records@azlibrary.gov
Signature:
E-Mail:
Date:
cconfer@elmirageaz.gov
10/10/2005
07/03/2003
5/6/1987
Paper
GS 1024
10364
Fire Investigation Reports Records - All Others (non arson)
12/24/1987
9/16/2017
GS 1024
10363
Fire Investigation Reports Records - Arson
Paper
Paper
10383
GS 1024
Program Records- Community CPR Class  registration records
7/11/1995
12/15/2012
0.25
0.50
0.25
Hold Harmless/Release/Waiver Agreements(Ride Alongs)
GS 1018
10282
1/5/2009
8/1/2017
Paper
0.25
Emergency Medical Service Records- Adults
Emergency Medical Service Records- Minors 
GS 1024
GS 1024
10359
10360
1/2/2012
10/1/2014
12/31/1996 8/27/2014
0.50
0.25
Paper
Paper
Fire Department
Fire Department

ARIZONA STATE
LIBRARY, ARCHIVES AND PUBLIC RECORDS
A DIVISION OF THE ARIZONA SECRETARY OF STATE
Joan Clark, State Librarian & Director
ARCHIVES AND RECORDS MANAGEMENT
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Revised 08/2013
An Equal Opportunity Employer
INSTRUCTIONS
Use this form ONLY for records that were destroyed and were on a current approved Retention Schedule.
In the top section enter the name of your Agency or Public Body, and include any subdivision breakdown for division, department or unit.
If additional pages are needed for reporting, please save and print the form and fill in the corresponding page numbers at the top of the form.
At the bottom of the form enter the Agency or Public Body name, date on which the records were destroyed, and the printed and signed name 
of the individual who actually performed or arranged with a contracted vendor for the destruction of the records.
Mail or e-mail the original completed form to the Arizona State Library, Archives, and Public Records, Records Management Center.  Fax 
copies are acceptable only if the received fax is legible.
RECORDS MANAGEMENT CENTER
1919 West Jefferson Street  •  Phoenix, Arizona  85009  •  Home Page:  http://www.azlibrary.gov/records
Phone:  (602) 926-3815  •  FAX:  (602) 256-2838  •  E-Mail:  records@azlibrary.gov
List the Record Series titles associated with the destruction using the exact record series name(s) found on the approved Retention Schedule 
being following.
Enter either the schedule number or approved date for the Retention Schedule you are following to determine eligibility for destruction.
Enter the item number from the authorized schedule you are following.
Enter the earliest date of records you are requesting to destroy under the Records Start Date column and the latest date for the records you are 
requesting to destroy under the Records End Date column.
Enter the format of the records to be destroyed under the Format: Paper, Digital, Microfilm column.
Enter the amount of records being destroyed under the Number of Files, Boxes, Reels or Electronic File Size column.