Airport Master Record (Newly Established Private Airports) {FAA 5010-5}

U.S. Department of Transportation Federal Aviation Administration FAA Form 5010-5, Airport Master Record Paperwork Reduction Act Burden Statement A federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply with a collection of information subject to the requirements of the Paperwork Reduction Act unless that collection of information displays a currently valid OMB Control Number. The OMB Control Number for this information collection is 2120-0015. Public reporting for this collection of information is estimated to be approximately 60 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, completing and reviewing the collection of information. All responses to this collection of information are critical to aviation safety and will be published in flight information handbooks and charts for pilot use. The data is also necessary for airspace studies conducted under 49 USC 329(b). The data is public in nature and is the agency's source for the information used in aeronautical charts and flight information publications. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to the FAA at: 800 Independence Ave. SW, Washington, DC 20591, Attn: Information Collection Clearance Officer, ASP-110. Instructions for Form 5010-5, Airport Master Record Use this form when establishing a new private-use landing area to notify the FAA that the landing area is now operational. Please complete the form and return it to the FAA Regional Office or Airports District Office that airspaced the landing area. For a complete description of each data element and acceptable entries, see Avdisory Circular 150/5200-35A: http://www.faa.gov/airports/resources/advisory_circulars/index.cfm/go/document.information/ documentNumber/150_5200-35A Contact the office if you have any questions regarding this form. To obtain a mailing or email address for submitting the form, see http://www.faa.gov/airports/news_information/contact_info/regional/ FAA Form 5010-5 American LegalNet, Inc. www.FormsWorkFlow.com U.S. DEPARTMENT OF TRANSPORTATION FEDERAL AVIATION ADMINISTRATION AIRPORT MASTER RECORD 4. STATE: 6 REGION/ADO: >70 FUEL: FORM APPROVED OMB 2120-0015 8/31/2019 >1 ASSOC. CITY: >2 AIRPORT NAME: 3 CBD TO AIRPORT (NM): GENERAL 10 OWNERSHIP: 11 OWNER: 12 ADDRESS: 13 PHONE NR: 14 MANAGER: 15 ADDRESS: 16 PHONE NR: 17 ATTENDANCE SCHEDULE: MONTHS DAYS LOC ID: 5 COUNTY: 7 SECT AERO CHT: SERVICES FAA SITE NR: BASED AIRCRAFT 90 SINGLE ENG: 91 MULTI ENG: 92 JET: TOTAL 93 HELICOPTERS: 94 GLIDERS: 95 MILITARY: 96 ULTRA-LIGHT: HOURS FACILITIES >80 ARPT BCN: >81 ARPT LGT SKED: >82 UNICOM: 83 WIND INDICATOR: 84 SEGMENTED CIRCLE: 85 CONTROL TWR: 86 FSS: 87 FSS ON ARPT: 88 FSS PHONE NR: 89 TOLL FREE NR: 18 AIRPORT USE: 19 ARPT LAT: 20 ARPT LON: 21 ARPT ELEV: 22 ACREAGE: >23 RIGHT TRAFFIC: 24 NON-COMM LANDING: RUNWAY DATA >30 RUNWAY IDENT: >31 LENGTH: >32 WIDTH: 33 SURF TYPE-COND: LIGHTING/APCH AIDS >40 EDGE INTENSITY: >42 RWY MARK TYPE-COND: OBSTRUCTION DATA 50 PART 77 CATEGORY: 51 DISPLACED THLD: 52 CTLG OBSTN: 53 OBSTN MARKED/LGTD: 54 HGT ABOVE RWY END: 55 DIST FROM RWY END: / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / (>) ARPT MGR PLEASE ADVISE FSS IN ITEM 86 WHEN CHANGES OCCUR TO ITEMS PRECEDED BY> >1 I 0 REMARKS: 111 OWNER/MANAGER SIGNATURE FAA Form 5010-5 (4/96) SUPERSEDES PREVIOUS EDITION 113 DATE: NSN: 0052-00-845-3003 American LegalNet, Inc. www.FormsWorkFlow.com