Free 854 - Federal

FCC 854

FEDERAL COMMUNICATIONS COMMISSION

Information and Instructions

Approved by OMB 3060 -0139 Est. Avg. Burden Per Response: 30 minutes

Application for Antenna Structure Registration
NOTICE TO INDIVIDUALS REQUIRED BY THE PRIVACY ACT OF 1974 AND THE PAPERWORK REDUCTION ACT OF 1995
We have estimated that each response to this collection of information will take on average 30 minutes. Our estimate includes the time to read the instructions, look through existing records, gather and maintain required data, and actually complete and review the form or response. If you have any comments on this estimate, or on how we can improve the collection and reduce the burden it causes you, please write the Federal Communications Commission, AMD-PERM, Washington DC 20554, Paperwork Reduction Project (3060-0139). We will also accept your comments via the Internet if you send them to [email protected]. Please do not send completed application forms to this address. You are not required to respond to a collection of information sponsored by the Federal government, and the government may not conduct or sponsor this collection unless it displays a currently valid OMB control number with this notice. This collection has been assigned OMB control number 3060-0139. The FCC is authorized under the Communications Act of 1934, as amended, to collect the personal information we request in this form. We will use the information you provide to determine whether approving this application is in the public interest. If we believe there may be a violation or potential violation of a statute, FCC regulation, rule or order, your application may be referred to the Federal, state, or local agency responsible for investigating, prosecuting, enforcing or implementing the statute, rule, regulation or order. In certain cases, the information in your application may be disclosed to the Department of Justice or a court or adjudicative body when (a) the FCC; or (b) any employee of the FCC; or (c) the United States Government, is a party to a proceeding before the body or has an interest in the proceeding. As of December 3, 2001, all parties and entities doing business with the Commission must obtain a unique identifying number called the FCC Registration Number (FRN) and supply it when doing business with the Commission. Failure to provide the FRN may delay the processing of the application. This requirement is to facilitate compliance with the Debt Collection Improvement Act of 1996 (DCIA). The FRN can be obtained electronically through the FCC webpage at http://wireless.fcc.gov/uls/ (select FCC Registration Number [FRN] Commission Registration System {CORES}) or by manually submitting FCC Form 160. FCC Form 160 is available from the FCC's web site at http://www.fcc.gov/formpage.html, by calling the FCC's Forms Distribution Center (800) 418-FORM (3676), or from Federal Communications Commission Fax Information System by dialing (202) 418-0177. This notice is required by the Privacy Act of 1974, Public law 93-579, December 31, 1974, 5 U.S.C. Section 552a (e) (3) and the Paperwork Reduction Act of 1995, Public law 104-13, October 1, 1995, 44 U.S.C. 3507,

FCC Form 854 Instructions - Page 1 January 2006

General Instructions
Purpose of form This FCC form is to be used to register structures used for wire or radio communication service in any area where radio services are regulated by the Commission; to make changes to existing registered structures or pending applications; or to notify the Commission of the completion of construction or dismantlement of structures, as required by Title 47 of the Code of Federal Regulations, Chapter 1, Part 17 (FCC Rules Part 17). Note: This is not an application for authorization to build a radio facility or transmit from it. Who Must File FCC Form 854 and When Registration with the Commission is required before any construction or alteration of an antenna structure, which requires notification to the Federal Aviation Administration (FAA). (Prior to registering with the Commission, an antenna structure owner (or tenant licensee in certain cases where the owner is unable to register see - Title 47 of the Code of Federal Regulations, Chapter 1, Part 17.4(e)) must have notified the FAA (via FAA Form 7460-1) and received a final determination of 'no hazard' from the FAA.) Form 854 must also be filed to notify the Commission of the completion of construction of a registered antenna structure, and to notify the Commission of changes to an antenna structure registration or application. A separate FCC Form 854 must be filed to register each antenna structure or each tower of an array. FCC Form 854, in conjunction with Schedule A, may be filed to notify the Commission of changes that affect multiple antenna structure registrations and applications in exactly the same way. Notification to the FAA (as prescribed in Title 47 of the Code of Federal Regulations, Chapter 1, Part 17.7) and, thus, registration with the Commission is required for any of the following: 1) Any construction or alteration of more than 60.96 meters (200 feet) in height above ground level at its site. 2) Any construction or alteration of greater height than an imaginary surface extending outward and upward at one of the following slopes: (a) 100 to 1 for a horizontal distance of 6.10 kilometers (20,000 feet) from the nearest point of the nearest runway of each airport as specified in paragraph 3(a, b, and c) below with its longest runway more than 0.98 kilometers (3,200 feet) in actual length, excluding heliport and seaplane bases without specified boundaries. (b) 50 to 1 for a horizontal distance of 3.05 kilometers (10,000 feet) from the nearest point of the nearest runway of each airport as specified in paragraph 3(a, b, and c) below with its longest runway no more than 0.98 kilometers (3,200 feet) in actual length, excluding heliport and seaplane bases without specified boundaries. (c) 25 to 1 for a horizontal distance of 1.52 kilometers (5,000 feet) from the nearest point of the nearest landing and takeoff area of each heliport specified in paragraph 3(a, b, and c) below. NOTE: Applicants can access the FCC's TOWAIR program via the Antenna Homepage (http://wireless.fcc.gov/antenna) to determine if a proposed construction or alteration meets the above criteria. on the Internet

3) Any construction of an antenna structure (or any alteration of an antenna structure that would increase its height) on any of the following airports (including heliports): (a) An airport that is available for public use and is listed in the Airport Directory or current Airman's Information Manual or in either the Alaska or Pacific Airman's Guide and Chart Supplement. (b) An airport under construction that is the subject of a notice or proposal on file with the Federal Aviation Administration and, except for military airports, it is clearly indicated that the airport will be available for public use. (c) An airport that is operated by one of the armed forces of the United States. 4) When requested by the FAA, any construction or alteration that would be in an instrument approach area (defined in the FAA standards governing instrument approach procedures) and available information indicates it might exceed an obstruction standard of the FAA.

FCC Form 854 Instructions - Page 2 January 2006

Registration with the FCC is not required in the above circumstances if construction or alteration meets one of the following criteria as identified in Title 47 of the Code of Federal Regulations, Chapter 1, Part 17.14:
1)

Any object that would be shielded by existing structures of a permanent and substantial character or by natural terrain or topographic features of equal or greater height, and would be located in the congested area of the city, town or settlement where it is evident beyond all reasonable doubt that the structure so shielded will not adversely affect safety in air navigation. Any antenna structure of 6.10 meters (20 feet) or less in height except one that would increase the height of another antenna structure. Any air navigation facility, airport visual approach or landing aid, aircraft arresting device, or meteorological device of a type approved by the administrator of the Federal Aviation Administration, the location and height of which is fixed by its functional purpose.

2)

3)

Information Current and Complete Information filed with the FCC must be kept current and complete. The applicant must notify the FCC regarding any substantial and significant changes in the information furnished in the application(s). See Title 47 of the Code of Federal Regulations, Chapter 1, Part 1.65 (47 CFR 1.65). Applicable Rules and Regulations Applicants should obtain the relevant parts of the FCC's rules in Title 47 of the Code of Federal Regulations (47 CFR). Copies of 47 CFR may be purchased from the Superintendent of Documents; Government Printing Office; Washington, DC 20402; (202) 512-1800. Refer also to the Government Printing Office's Website at http://www.access.gpo.gov. Some FCC rules require applicants to attach one or more exhibits to an application in addition to the information requested in the application form. Processing Fee and Filing Location No fee is required to register an antenna structure. In lieu of electronically, submit one original, signed FCC Form 854 to the following address (detach and retain the instructions prior to mailing): Federal Communications Commission Spectrum Management Resources & Technologies Division 1270 Fairfield Road Gettysburg, PA 17325-7245 Hand-deliveries and messenger-deliveries should be delivered to Federal Communications Commission, 1280 Fairfield Road, Gettysburg, PA 17325. For Assistance For assistance with this application, contact the Federal Communications, 1270 Fairfield Road, Gettysburg, PA 17325-7245, call (877) 480-3201 (TTY 717-338-2824) and select option #2; or visit http://esupport.fcc.gov. Electronic Filers Information about electronic filing is available at http://wireless.fcc.gov/antenna. Applicants filing electronically should follow procedures contained in online help files. For technical assistance with filing electronically, contact the Wireless Telecommunications Bureau Technical Support line, (877) 480-3201.

FCC Form 854 Instructions - Page 3 January 2006

Specific Instructions
Purpose of Application ITEM 1 - Enter the appropriate two-letter purpose code in the brackets provided. Enter only one code. NE = New Antenna Registration. Enter NE in the brackets to indicate that this is an application to register an antenna structure that has not been registered. MD = Modification of Registered Antenna Structure. Enter MD in the brackets to indicate that this is an application to change antenna structure information for a structure, which has already been registered with the Commission. Enter the seven-digit antenna structure registration number in Item 2B. Enter the date the antenna structure was constructed in Item 2C. A modification can be filed only if the antenna structure is constructed (i.e., you have previously filed a notification of construction). CA = Cancel Registration. Enter CA in the brackets to cancel your registered, but not constructed, (project abandoned) antenna structure. Provide the seven-digit antenna structure registration number in Item 2B or, if you are canceling multiple registrations for unconstructed antenna structures, provide the antenna structure registration numbers on FCC Form 854, Schedule A. You may only cancel a registration for an antenna structure that has not been constructed. AU = Administrative Update. To request a change of any administrative data on an antenna structure registration. Enter AU in the brackets to request changes to the following: Changes in antenna structure owner's name (without a change in ownership) address, phone number, E-mail, or contact information. Provide the seven-digit antenna structure registration number in Item 2B or, if you are requesting an administrative update to more than one registration, provide the antenna structure registration numbers on FCC Form 854, Schedule A. Dl = Antenna Structure Dismantlement. Enter Dl in the brackets to indicate that this is an application to notify the Commission that the constructed antenna structure no longer exists. This could be the result of the owner dismantling the structure, natural disaster, erosion, etc. Enter the month, day and year (mmddyy) the structure was dismantled or destroyed in Item 2D and provide the seven-digit antenna structure registration number in Item 2B. WD = Withdraw. Enter WD in the brackets to indicate that this is a request to withdraw a previously filed, currently pending application. Provide the application file number in Item 2A or, if you are withdrawing multiple pending applications, provide the file numbers on FCC Form 854, Schedule A. AM = Amendment. Enter AM in the brackets to indicate that this is a request to amend a previously filed, currently pending application. Provide the file number of the application being amended in Item 2A. NT = Required Construction Notification. Enter NT in the brackets to notify the Commission that the construction/alteration has been completed as registered. Provide the seven-digit antenna structure registration number in Item 2B and enter the date of construction or alteration in Item 2C. DU = Enter DU in the brackets to request a duplicate of your antenna structure registration. Provide the seven-digit antenna structure registration number in Item 2B or, if you are requesting duplicates of more than one registration, provide the antenna structure registration numbers on FCC Form 854, Schedule A. OC = Ownership Change. Enter OC in the brackets to indicate that this is an application to notify the Commission of a change in ownership for a registered antenna structure. Provide the seven-digit antenna structure registration number in Item 2B or, if you are requesting an ownership change to more than one registration, provide the antenna structure registration numbers on FCC Form 854, Schedule A. Note: For an ownership change, the assignee (i.e. the entity acquiring ownership of the structure) must provide the new ownership information and sign the form. The only information required of the assignor (i.e. the entity to whom the structure is currently registered) is Item 4. ITEMS 2A or 2B -Enter File Number or Antenna Structure Registration Number that this application pertains to. If applying for purpose code DU, WD, CA, AU or OC and this application pertains to more than one registration or application, leave Items 2A and 28 blank and complete and attach FCC Form 854, Schedule A, Schedule For Changes Affecting Multiple Antenna Structure Registration or File Numbers. ITEM 2C-If purpose code is MD or NT, enter date constructed or last altered. ITEM 2D-If purpose code is DI, enter date of dismantlement.

FCC Form 854 Instructions - Page 4 January 2006

Antenna Structure Ownership Information ITEM 3 - FCC Registration Number (FRN) of Owner/Assignee. Provide the ten digit FRN assigned by the Commission Registration System (CORES). The FRN is a unique entity identifier for everyone doing business with the Commission. The FRN can be obtained electronically through the FCC web page at http://wireless.fcc.gov/uls/ (Select FCC Registration Number (FRN) Commission Registration System (CORES)) or by manually submitting FCC Form 160. FCC Form 160 is available from the FCC's web site at http://www.fcc.gov/formpage.html, by calling the FCC's Forms Distribution Center 800-418-FORM (3676), or from Federal Communications Commission Fax Information System by dialing (202) 418-0177. Note: When filing for an Ownership Change (OC), this would be the new owner's FRN. ITEM 4 - FCC Registration Number (FRN) of Assignor. When filing an Ownership Change (OC), please provide the ten digit FRN of the previous antenna structure owner. ITEMS 5-6 -Enter the full legal name of the owner/assignee of the antenna structure. If owner/assignee is: 1) An individual, enter First Name, Middle Initial, Last Name, Suffix and leave Business Name and Attention fields blank. 2) An individual 'doing business as' (a sole proprietorship), enter First Name, Middle Initial, Last Name, Suffix and leave Business Name and Attention fields blank. 3) A partnership doing business under a firm or company name, enter the full name of the partnership in the Business Name field and leave First Name, Middle Initial, Last Name and Suffix fields blank. 4) An unincorporated association, enter the name of the association in the Business Name field and leave First Name, Middle Initial, Last Name and Suffix fields blank. 5) A corporation or governmental entity, enter the full legal name of the entity in the Business Name field and leave First Name, Middle Initial, Last Name and Suffix fields blank. If entering a business name in Item 6, complete Items 15-23 with the business contact information. ITEMS 7-12 - Enter the mailing address of the owner/assignee. You may enter a post office box number in Item 8 or a street address in Item 9, or enter information for both items. Enter the city, state, and ZIP Code in Items 10, 11 and 12, respectively. ITEM 13 - Enter the area code and telephone number where the owner/assignee can be reached during normal business hours. ITEM 14 - Provide an E-Mail address, if one is available, where the owner/assignee can receive electronic mail from the Commission regarding the form. Contact Representative Information ITEMS 15-23 - These items identify the contact representative, if different from the owner/assignee or if the owner is a business. This is usually the headquarters office of a large company, the law firm or other representative of the owner/assignee, or the person or company that prepared or submitted the application on behalf of the owner/assignee. If there is a question about the application, an FCC representative will communicate with the applicant's contact representative.

FCC Form 854 Instructions - Page 5 January 2006

Antenna Structure ITEM 24-25 -Enter the geographic coordinates and direction of the location, referenced to the North American Datum of 1983 (NAD83). This data should correspond to the site data listed on your FAA Determination (see Item 36). This information can be determined using a GPS receiver with differential correction, a 7.5 minute topographical quadrangle map of the area, or you may consult the city or county surveyor in your area. Topographical maps may be purchased from the U.S. Geological Survey. For more information or ordering assistance, caIl1-800-HELPMAP; write USGS Information Services, Box 25286, Denver, CO 80225; or visit http://mapping.usgs.gov/esic/to_order.html. Note: Location coordinates (latitude and longitude) for sites in the Continental United States, Puerto Rico, the U.S. Virgin Islands, Alaska, Hawaii, American Samoa, and Guam must be referenced to the North American Datum of 1983 (NAD83). Coordinates for certain Pacific Island sites should be referenced to the applicable local datum. If the source from which you obtain the coordinates still utilizes an older datum (i.e., NAD27, PRD40), you must convert to NAD83. Conversion routines and instructions for Pacific Island coordinate reporting are available through the Internet at http://wireless.fcc.gov/uls/utilities/nadcon.html. Enter the latitude using the format DD-MM-SS.S, where the degrees (DD) term can have a value in the range of 0 to 72, minutes (MM) can range from 0 to 59, and seconds (SS.S) can range from 0 to 59.9. Specify the direction as either 'N' for North or 'S' for South. Enter the longitude using the format DDD-MM-SS.S, where the degrees (DDD) term can have a value in the range of 64 to 180, minutes (MM) can range from 0 to 59, and seconds (SS.S) can range from 0 to 59.9. Specify the direction as either 'E' for East or 'W' for West. ITEM 26-28 -Enter the requested information about the antenna structure location. If the location of the structure does not have a street address, describe the location in such a way that it can be located readily. For example, if the structure is on a mountain, give the name of the mountain; for structures at rural locations, indicate the route numbers of the nearest highway/intersection and the distance and direction from the nearest town. Post Office Boxes are not acceptable. Enter the city and state in which the antenna structure is actually located. Example: (Item 26) Near Rt. 66, 1.3 km NNW of (Item 27) Erie (Item 28) PA

ENGLISH TO METRIC CONVERSIONS: The following English to Metric equivalents should be used to convert heights and distances, to the nearest tenth, where necessary: 1 foot = 0.3048 meters (Example: 350 feet x 0.3048 = 106.68 meters. Round to 106.7.) 1 mile = 1.6093 kilometers (Example: 5 miles x 1.6093 = 8.0465 kilometers. Round to 8.0.) ITEM 29 - Enter in meters rounded to the nearest tenth, the elevation above mean sea level of the ground at the antenna structure site. This may be obtained from the FAA Final Determination. Be sure to convert feet to meters and round to the nearest tenth. Refer to letter 'a' of the antenna structure examples below. ITEM 30 -Enter the overall height above ground (AGL) in meters rounded to the nearest tenth, of the entire antenna structure to the highest point, INCLUDING any appurtenances. You must include antennas, dishes, and obstruction lighting. Refer to letter 'c' of the antenna structure examples below. This may be obtained from the FAA Final Determination. Be sure to convert feet to meters and round to the nearest tenth. ITEM 31 - Enter the overall height in meters above mean sea level (AMSL) rounded to the nearest tenth. This will be the total of Items 29 and 30. This may be obtained from the FAA Final Determination. Be sure to convert feet to meters and round to the nearest tenth. ITEM 32 - Enter the height above ground in meters rounded to the nearest tenth, to the highest point of the supporting structure only (WITHOUT appurtenances). Be sure to convert feet to meters and round to the nearest tenth. If your antenna structure consists of a building/tower combination, include any elevator shaft, flagpole, or penthouse in the overall structure height, but not the antenna, tower, pole or mast. If your antenna structure is a tower only, include the height of the tower but not the antenna. Refer to letter 'b' of the antenna structure examples below. Antenna Structure Examples

FCC Form 854 Instructions - Page 6 January 2006

ITEM 33 -Enter the code from the following valid structure types for the type of supporting structure which the antenna is or will be mounted on. Refer to letter 'b' of the antenna structure examples in these instructions: Code B BANT BMAST BPIPE BPOLE BRIDG BTWR MAST NNTANN* NTOWER** PIPE POLE RIG SIGN SILO STACK TANK TOWER TREE UPOLE Definition Building Building with Antenna on Top Building with Mast Building with Pipe Building with Pole Bridge Building with Tower Mast Antenna Tower Array Multiple Structures Any type of Pipe Any type of Pole Oil or other type of Rig Any type of Sign or Billboard Any type of Silo Smoke Stack Any type of tank (water, gas. etc.) Free standing or guyed structure used for communication purposes When used as a support for an antenna Utility Pole/Tower used to provide service (electric/telephone. etc.)

*Valid Tower Arrays. Code Definition: The first NN indicates the number of towers in an array. The second NN indicates the position of that tower in the array (ex: 3TA2 would identify the second tower in a three tower array; 14TA12 would identify the twelfth tower in a fourteen tower array). **Valid Multiple Structures. Code Definition: The N indicates the number of structures where multiple antenna structures are present (i.e. 2TOWER, 3TANK, 6BMAST). ITEMS 34-35 - If the type of structure is an array, enter the geographic coordinates for the 'center' of the array, referenced to the North American Datum of 1983 (NAD83). Enter the latitude, longitude and direction in the same format shown in Items 24 and 25. Each applicable antenna structure within an AM broadcast array must be registered separately with the FCC. In most cases, however, antenna structure arrays are studied by the FAA using a single set of coordinates representing the 'center' of the array, or possibly the structure closest to a nearby airport facility. The coordinates referenced by the FAA in its Determination of No Hazard for an array may differ from the actual coordinates of the antenna structure being registered. (NOTE: Items 24-28 should reflect the location and actual coordinates of the individual structure being registered within the array.) FAA Notification ITEMS 36-37 - Provide the FAA Study Number and Issue Date of the most current FAA Determination of 'No Hazard' issued for this structure. NOTE: Do not submit this Form 854 for new proposals or alterations to existing structures until you receive an FAA Final Determination. Do not include a copy of the Determination. Environmental Assessment ITEM 38 - This item must be answered, either 'Y' or `N'. Answer 'Y' if a Commission grant of this application may have a significant environmental impact as defined by Title 47 of the Code of Federal Regulations, Chapter 1, Part 1.1307(a). Briefly, Commission grant of an application may have a significant environmental impact if any of the following are proposed: 1) A structure is to be located in a sensitive area (i.e., an officially designated wilderness area, a wildlife preserve area, a flood plain) or will physically or visually affect sites significant in American history. 2) A structure whose construction will involve significant change in surface features. 3) An antenna structure that will be equipped with high intensity white lights and will be located in a residential neighborhood (as defined by the applicable zoning law). If you answer 'Y' (Yes), submit the required Environmental Assessment (EA) along with this application. The EA should include: 1) A description of the facilities as well as supporting structures and appurtenances, and a description of the site as well as the surrounding area and uses. If high intensity lighting is proposed or utilized within a residential area, the EA must also address the impact of lighting upon the residents.

FCC Form 854 Instructions - Page 7 January 2006

2) A statement as to the zoning classification of the site, and communications with, or proceedings before and determinations (if any) made by zoning, planning, environmental or other local, state or federal authorities on matters relating to environmental effect. 3) A statement as to whether construction of the facilities has been a source of controversy on environmental grounds in the local community. 4) A discussion of environmental and other considerations which led to the selection of the particular site and, if relevant, the particular facility; the nature and extent of unavoidable adverse environmental effects, and any alternative sites or facilities which have been or might reasonably be considered. Further details may be found in Sections 1.1308 and 1.1311 of the Commission's rules. Signature ITEMS 39 ­ 42 - These items must be completed. To be acceptable for filing, applications and amendments must be signed in accordance with Part 1 of the Commission's rules. The signor must be a person authorized to sign the application. Paper originals of applications must bear an original signature. On paper originals, neither rubber-stamped nor photocopied signatures are acceptable. For filers filing electronically, the electronic signature shall consist of the name of the applicant typed on the application as a signature. HOW AND WHERE TO NOTIFY THE FAA Notify the FAA of the proposed construction or alteration via FAA Form 7460-1 (Notice of Proposed Construction or Alteration). Forward the completed form to: Chief, Air Traffic Division, Federal Aviation Administration, and (Name of Office -see below). Notify the office having jurisdiction over the area within which the proposed construction or alteration will be located. The geographic area of jurisdiction for each FAA office is indicated below. Note: Contact the FAA to obtain copies of FAA Form 74601, or link to the FAA's Internet site http://www.faa.gov/ats/ata/ata400/7460-1f.pdf. ADDRESSES OF THE FAA REGIONAL OFFICES AAL - ALASKAN REGION (AK) Alaskan Region, Air Traffic Div AAL-530, 222 W 7th Ave #14, Anchorage, AK 99513-7587 Phone: (907) 271-5893 ACE - CENTRAL REGION (IA, KS, MO, NE) Central Region, Air Traffic Div ACE-520, 60 East 12st St, Kansas City, MO 64106 Phone: (816) 426-3408 (KS,MO) or (816) 426-3409 (IA, NE) AEA - EASTERN REGION (DC, DE, MD, NJ, NY, PA, VA, WV) Eastern Region, Air Traffic Div AEA-520, JFK International Airport, Jamaica, NY 11430 Phone: (718) 553-2616 AGL - GREAT LAKES REGION (IL, IN, MI, MN, ND, OH, SD, WI) Great Lakes Region, Air Traffic Div AGL-520, 2300 E Devon Ave, Des Plaines, IL 60018 Phone: (847) 294-7568 ANE - NEW ENGLAND REGION (CT, MA, ME, NH, RI, VT) New England Region, Air Traffic Div ANE-520, 12 New England Executive Park, Burlington, MA 01803-5299 Phone: (781) 238-7520 ANM - NORTHWEST MOUNTAIN REGION (CO,ID, MT, OR, UT, WA, WY) Northwest Mountain Region, Air Traffic Div ANM-520, 1601 Lind Ave SW, Renton, WA 98055-4056 Phone: (425) 227-2520 ASO - SOUTHERN REGION (AL, FL, GA, KY, MS, NC, PR, SC, TN, VI) Southern Region, Air Traffic Div ASO-520, 1701 Columbia Avenue, College Park, GA 30337 Phone: (404) 305-5685 ASW - SOUTHWEST REGION (AR, LA, NM, OK, TX) Southwest Region, Air Traffic Div ASW-520, 2601 Meacham Blvd, Fort Worth, TX 76137-0520 Phone: (817) 222-5531 AWP - WESTERN-PACIFIC REGION (AZ, CA, GU, HI, NV) Western-Pacific Region, Air Traffic Div AWP-520, 15000 Aviation Blvd, Hawthorne, CA 90260 Phone: (310) 725-6557

FCC Form 854 Instructions - Page 8 January 2006

FCC 854 Main Form

Approved by OMB 3060-0139 Est. Public Burden per Response: 30 minutes

FCC Application for Antenna Structure Registration
Purpose of Filing (Select only one) ( ) 1) NE - Registration of an antenna structure that has not been registered WD - Withdraw pending application(s) for registration MD - Modification of registered antenna structure AM - Amend pending application for registration CA - Cancel Registered Structure NT - Required Construction/Alteration Notification AU - Administrative Update DU - Request for Duplicate Registration - no changes DI - Notification of antenna structure dismantlement OC - Ownership Change (structure no longer exists) File Number: 2A) For purpose codes WD or AM, provide the file number of the pending application currently on file __________________ with the FCC. FCC ASR Number: 2B) If purpose codes of MD, CA, AU, DI, NT, DU or OC, provide FCC Antenna Structure Registration __________________ Number. 2C) If purpose code is MD or NT, provide date constructed or last altered (mmddyyyy). 2D) If purpose code is DI, give date of dismantlement (mmddyyyy). Antenna Structure Ownership Information 3) Owner/Assignee FCC Registration Number (FRN): 5) Legal Owner of Structure/Assignee (if individual): 6) Business Name (if other than individual): 7) Attention To: 8) P.O. Box: 10) City: 13) Telephone Number: ( ) And/Or 9) Street Address: 11) State: 14) E-Mail Address: 12) ZIP Code: First Name MI: 4) Assignor FCC Registration Number (FRN): Last Name: Suffix: _____/_____/______ _____/_____/______

Contact Representative Information (If the Owner/Assignee is a business or contact representative is different from the Owner/Assignee) 15) First Name: MI: Last Name: Suffix:

16) Business Name: 17) P.O. Box: And/Or 18) Street Address: 20) State: ) 21) ZIP Code:

19) City: 22) Telephone Number: (

23) E-Mail Address:

FCC Form 854 - Page 1 January 2006

Antenna Structure 24) NAD 83 Antenna Structure Latitude (DD-MM-SS.S): ( ) N or S 26) Address or Geographical Location: 27) City:

25) NAD 83 Antenna Structure Longitude (DDD-MM-SS.S): ( ) E or W

28) State: _____ .______ meters

29) Elevation of site above mean sea level (refer to `a' in antenna structure examples): 30) Overall (highest) height above ground (AGL) of antenna structure INCLUDING all appurtenances (antennas, dishes, lightning rods, obstruction lighting, etc.) (refer to `c' in antenna structure examples): 31) Overall height above mean sea level (sum total of Items 29 and 30): 32) Overall height above ground (AGL) of the supporting structure itself WITHOUT appurtenances (refer to `b' in antenna structure examples): 33) Indicate the code for the type of structure on which antenna will be mounted: (i.e. pole, building, water tank, silo, tower, etc.) (See instructions.) 34-35) If type of structure is an Array, provide coordinates for center of array below: 34) NAD 83 Array Center Latitude (DD-MM-SS.S): ( ) N or S

_____ .______ meters _____ .______meters

_____ .______meters

_________________

35) NAD 83 Array Center Longitude (DDD-MM-SS.S): ( ) E or W

FAA Notification 36) FAA Study Number: Environmental Assessment Would a Commission grant of Authorization for this location be an action, which may have a significant 38) ( ) Yes No environmental effect? See Section 1.1307 of 47 CFR. If `Yes', submit an environmental assessment as required by 47 CFR, Sections 1.1308 and 1.1311. Certification Statements 1) The applicant certifies that all statements made in this application and in the exhibits, attachments, or documents incorporated by reference are material, are part of this application, and are true, complete, correct, and made in good faith. 2) The applicant certifies that neither the applicant nor any other party to the application is subject to a denial of Federal benefits pursuant to Section 5301 of the Anti-Drug Abuse Act of 1988, 21 U.S.C. § 862, because of a conviction for possession or distribution of a controlled substance. See Section 1.2002(b) of the rules, 47 CFR § 1.2002(b), for the definition of "party to the application" as used in this certification.
Signature

37) Date Issued (mmddyyyy):

_______/_______/_______

39) Typed or Printed Name of Party Authorized to Sign First Name: 40) Title: 41) Signature:

MI:

Last Name:

Suffix:

42) Date:

WILLFUL FALSE STATEMENTS MADE ON THIS FORM OR ANY ATTACHMENTS ARE PUNISHABLE BY FINE AND/OR IMPRISONMENT (U.S. Code, Title 18, Section 1001) AND/OR REVOCATION OF ANY STATION LICENSE OR CONSTRUCTION PERMIT (U.S. Code, Title 47, Section 312(a)(1)), AND/OR FORFEITURE (U.S. Code, Title 47, Section 503).

FCC Form 854 - Page 2 January 2006

Instructions for FORM 854, SCHEDULE A SCHEDULE FOR CHANGES AFFECTING MULTIPLE ANTENNA STRUCTURE REGISTRATIONS OR FILE NUMBERS FCC Form 854, Schedule A, is an optional supplementary schedule for use with the Application for Antenna Structure Registration (FCC Form 854, Main Form). Use Schedule A when your purpose of filing (Item 1 on FCC Form 854, Main Form) is DU Duplicate, WD-Withdrawal, CA-Cancellation, AU-Administrative Update or OC-Ownership Change and the changes being made affect multiple registrations or file numbers in exactly the same way. FCC Form 854, Main Form, must be completed indicating only one of the purpose codes listed above. Complete Schedule A to indicate each antenna structure registration number or file number that is to be modified according to the changes indicated on the FCC Form 854, Main Form. Do not list any registration numbers or file numbers on FCC Form 854, Main Form, if you are attaching Schedule A. FCC Form 854 and Schedule A must be submitted together in accordance with the filing procedures outlined in the FCC Form 854, Main Form instructions.

FCC Form 854 Schedule A Instructions - Page 1 January 2006

FCC 854 Schedule A

Schedule for Changes Affecting Multiple Antenna Structure Registration Numbers or File Numbers

Enter only multiple Antenna Structure Registration Numbers or only multiple File Numbers for the following FCC Form 854 purposes: WD - Withdraw pending application(s) for registration (File Numbers) DU - Request for Duplicate Registration CA - Cancel Registered Structure AU - Administrative Update or OC - Ownership Change (Registration Numbers) Note: FCC Form 854 allows the selection of only one purpose per submission. Each Schedule A or groups of Schedule A filed with the FCC Form 854 must use the same purpose. Antenna Structure Registration Number or File Number Antenna Structure Registration Number or File Number Antenna Structure Registration Number or File Number Antenna Structure Registration Number or File Number

FCC Form 854 Schedule A - Page 1 January 2006