Technical Reference Data Record {FAA 6030-17}

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 American LegalNet, Inc. www.FormsWorkflow.com OMB 2120-0014 02/28/2009