CLASSIFIED MATERIAL DESTRUCTION RECORD

1. DATE (YYYYMMDD)

CUI (WHEN COMPLETED)

CLASSIFIED MATERIAL DESTRUCTION RECORD

2. MILITARY DEPARTMENT OR AGENCY NAME

3. OFFICE SYMBOL OR COMPONENT NAME

5. NUMBER OF BAGS (NOTE: There is a ten (10) pound weight limit per bag.) a. NUMBER OF UNCLASSIFIED OR CUI BAGS b. NUMBER OF CONFIDENTIAL BAGS c. NUMBER OF SECRET BAGS d. NUMBER OF TOP SECRET BAGS e. NUMBER OF SCI BAGS f. TOTAL NUMBER OF BAGS g. REMARKS

4. TELEPHONE NUMBER (Include Area Code)

6. TOTAL NUMBER OF HARD DRIVES (NOTE: Internal platters and circuit boards only, no metal housing.)

7. NAME OF DELIVERY PERSON(S) (Delivery person be cleared at the same level of, or higher than the material delivered.)

8. RECEIVED BY (To be completed by incinerator plant personnel/driver)

PENTAGON CLASSIFIED WASTE DESTRUCTION FACILITY 300 Boundary Channel Drive Arlington VA 22202

TELEPHONE (703) 695-1828

DD FORM 2843, OCT 2020

CUI (WHEN COMPLETED)

Controlled by: PFPA Category: OPSEC LDC: DL (PFPA Only)

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