0
Form Approved
MAJOR REPAIR AND ALTERATION
OMS No. 2120-0020
US Department
(Airframe, Powerplant, Propeller, or Appliance)
For FAA Use Only
of_Transportation
F~d~ral Aviation
Office Identification
Administration
INSTRUCTIONS: Print or type all entries. See FAR
43.9, FAR 43 Appendix B, and AC 43.9-1 (or subsequent revision thereof) for instructions
and
disposition of this form. This report is required by law (49 U.S.C. 1421 ). Failure to report can result in a civil penalty not to exceed $1,000
for each violation I Section 901 of Federal Aviation Act of 1958).
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Make··
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Model·
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BELL HELICOPTER TEXTRON 412EP
1. Aircraft Serial No.
Nationality and Registration Mark
36106
USA N412SV
Name
(As shown on registration certificate) Address (As shown on registration certificate)
....
2. Owner AEROGRAPHICS, INC.
P.
0. BOX 2190
MANASSAS, VA 20108-0826
3. For FAA Use Onlv
4. Unit Identification
.. - .
5. Type
Unit Make Model
Serial No. Repair Alteration
AIRFRAME
----'."'--::.---- (As described in Item 1 above) ----------
. '
x
POWE RP LANT
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PROPELLER
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Type
..
APPLiAN.CE
'··' ....
Manufacturer
6. Conformity Statement
A. Agency's Name and Address B.
Kind of Agency C. Certificate No.
U.S. Certificated Mechanic
EDWARDS
& ASSOCIATES, INC.
Foreign Certificated Mechanic
PO BOX 3689
x
Certified Repair Station
FKFR930D
BRISTOL TN 37625
Manufacturer
D. I certify
that the repair and/or alteration made to the unit(s) identified in item 4 above and described on the reverse or attachments
hereto have been made in accordance with
the requirements of Part 43 of the U.S. Federal Aviation Regulations and that the
information furnished herein is true and correct to the best of my knowledge.
/J
Date Signature of Authorized lndivinrnal fl/
01/DEC/2006
ALAN STELZIG
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7. Annroval for Return To Service
Pursuant to the authority given persons specified below, the unit identified in item
4 was inspected in the manner prescribed by the
Administrator of the Federal Aviation Administration and is
® APPROVED D REJECTED
, ..
. ,
FAA Flt. Standards
Manufacturer Inspection Authorization
Oth'?r (Specify)
'·
Inspector
"
BY
FAA Designee
x Repair Station
Person Approved by
Transport Canada
'
.,·
Airworthiness Group
/}
Date of Approval or Rejection
Certificate or
Signature of Authorized
1~.z~~pf"
'
Designation No. ---
01/DEC/2006
FKFR930D
ALAN STELZIG · · ;;:;- / // ----~
FAA Form 337 (12-88)
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