0
Form Approved
MAJOR REPAIR AND ALTERATION
OMB No. 2120-0020
US Department
(Airframe, Powerplant, Propeller, or Appliance)
For FAA Use Only
ofTransportation
Federal Aviation
Office Identification
Administration
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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 USAN26NY
Name
(As shown on registration certificate)
Address (As shown on registration certificate)
2. Owner UNITED AIR SURVEYS, INC. P. 0. BOX 1195
LAKEHURST, NJ 08733-0695
3. For FAA Use Onlv
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-
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4. Unit Identification
5. Type
Unit
Make
Model Serial No. Repair
Alteration
AIRFRAME
----------- (As described in Item 1 above)----------
x
POWE RP LANT
PROPELLER
Type
APPLIANCE
,.
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.
Date
Signature of Authorized Individual
/l
11/14/03
ALAN STELZIG
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7. Annroval for Return To Servi<!e
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
Inspector
Manufacturer Inspection Authorization
Other
(Specify)
BY
FAA Designee
x
Repair Station
Person Approved by
Transport Canada
Airworthiness Group
Date of Approval or Rejection
Certificate or
Signature of Authorized
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Designation No.
11/14/03
FKFR930D ALAN STELZIG
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FAA Form 337 (12-88)
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