FAA-6030-17 Technical Reference Data Record

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

Equipment/System Type

Serial No.

Facility Ident.
Code
Frequency

S

C

F

T

M

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

FAA Form 6030-17 (6/00)

OMB 2120-0014 02/28/2009

Signature

Title

Electronic Version (Adobe)

NSN: 0052-00-895-4000