District: Signature of Person
Certifying
Accuracy of this Report:
(Signature) (Title)
Site: Site Address:
Date:
|
Date
Acquired |
Name of
Equipment |
Kind of
Equipment |
Description
& Serial Number |
Manuf. and
Model Number |
Quantity
|
Original
Cost |
Location
of Equipment |
Disposal
Date |
Means of
Disposal |
|
|
|
|
|
|
|
|
|
|
|