Free TECHNICAL REFERENCE DATA RECORD - Federal

Paperwork Reduction Act Statement: This form requires that the sponsor fill out this form at the end of commissioning their facility, which will include equipment adjustments and all meter readings. We estimate 113 commissionings annually and FAA Form 6030-17 requires 1 hour to complete. Completion of this form is mandatory. An agency may not conduct or sponsor and a person is not required to respond to a collection of information unless it displays a currently valid OMB number. The OMB number associated with this collection is 2120-0014. Comments concerning the accuracy of this burden and suggestions for reducing the burden should be directed to the FAA at: 800 Independence Ave SW, Washington, DC 20591, Attn: Information Collection Clearance Officer, ABA 20. Location (City/State) Date Prepared Page No.

TECHNICAL REFERENCE DATA RECORD
Cost Center Code Location Ident. Facility Alpha Code Facility Ident. Code Frequency S C F T M

Equipment/System Type

Serial No.

Optional Use

Reference Handbook/Directive (Number and Title/Subject)

Reference PAR/DOC Number

Parameters

STD Values

Initial/Auth. Tolerances Lower Upper Limits Limits

Revisions Measured Values Type Date Initials

Other data specified by the Washington or Regional Offices:

Date

Signature

Title

FAA Form 6030-17 (6/00)

Electronic Version (Adobe)

NSN: 0052-00-895-4000

OMB 2120-0014 02/28/2009