0
Form Approved
MAJOR REPAIR AND ALTERATION
OMB No. 2120-0020
us
Oepatmenr
(Airframe, Powerplant, Propeller, or Appliance)
For FAA Use Only. ,..,
a Tron5P(l(IOIJOn
Office ldentifi~S(b N.
~
Federal Alllatlon
Administration At,"'1
INSTRUCTIONS: Print or type all entries. See FAR 43.9, FAR 43 Appendix B, and AC43.9-1 (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 notto exceed $1,000
for each such violation (Section 901 Federal Aviation Act of 1958).
Make
Model
1. Aircraft
Bell
412EP
Serial
No.
Nationality and Registration Mark
36106
USA N82628
Name (As shown on registration certificate)
Address (As shown on registration certificate)
2. Owner
Bell Helicopter Textron,
Inc. P.O.
Box
482 ..
~
.
Ft. Wor1=;h,
TX 76101
-,
.~_.,~y~ :E~-·,:~·
"ii~.\
3. For FAA Use Only
AC
a.xr.io
•
l{l
APPM ·
82
A3
RECEIVED
B!
A4
84
AS
DEC
1 3 1995
BS
AS
B.!L.
4. Unit Identification
ll
87
·-
Unit
Make
Model
~
...
ti:al 11. h.
cs
Repair
Alte ati n
AIRFRAME
,.,..,.,.,..,.,.,..,..,.,..,..,.,.,.,..,..,.,..,.,(As described in Item 1 above) .,..,.,.,.,.,..,..,..,..,..,.., • .,.,..,..,.,.,..,.
x
POWERPLANT
'
PROPELLER
Type
I
APPLIANCE
Manufacturer
6. Conformity Statement
A. Agency's Name and Address B. Kind of Agency C.· Certificate No.
Premier Aviation, Inc.
U.S. Certificated Mechanic
Limited Airframe
2621 Aviation Pkwy.
Foreign Certificated Mechanic
Radio Class
I,II,III
Grand Prairie,
TX 75052
x
Certificated Repair Station
Limited Instrument
Manufacturer
IPTR140L
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
12/5/95
Les
Gerrard
;zC
A
- -
~
7. Approval for Return To Service
"·
Pursuant to the authority given persons specified below, the fit identified in item 4 was inspected in the manner prescribed by the
Administrator of the Federal Aviation Administration and is APPROVED O 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 lndividuf
_ /~
Desi~ation
No.
12/5/95
IP Rl40L
Craig W. Hibner
6/'Al,,
~
J
--- fl
FAA Form 337 112-88)
,Y
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