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Form Approved
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MAJOR REPAIR AND ALTERATION
OMB No. 2120-0020
US Department
(Airframe, Powerplant, Propeller, or Appliance)
v
ofTransportation
For FAA Use Only
Federal Aviation
Office Identification S (!)
03
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 Section 901 of Federal Aviation Act of 1958).
·, Make
Model
BELL HELICOPTER TEXTRON
412EP
1. Aircraft
Serial No. Nationality and Registration Mark
36106
USA N26NY
Name
(As shown on registration certificate) Address (As shown on registration certificate)
2. Owner
UNITED AIR SURVEYS INC PO BOX 1195
LAKEHURST NJ 08733-0695
3. For FAA Use Onlv
4. Unit Identification
5. Type
Unit Make Model
Serial No. Repair Alteration
x
AIRFRAME
----------- (As described in Item 1 above) ----------
POWE RP LANT
PROPELLER
Type
APPLIANCE
Manufacturer
6. Conformity Statement
A. Aaencv's Name and Address
B. Kind of Aqency
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.
Date
Signature of Authorized Individual
1-17-05
David Van Fleet
()._::.;
~
Mr
7. Aooroval 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
181 APPROVED D REJECTED
FAA Flt. Standards
Manufacturer
Inspection Authorization
Other
(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 Individual
Designation No.
.1)__:::; t! ~r
1-17-05
FKFR930D
David Van Fleet
FAA Form 337
(12-88)
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