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. 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 2120-0014. Public reporting for this collection of information is estimated to be approximately 1 hour 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 mandatory under FAR Part 171. Send comments regarding this burden estimate or any other aspect of this
collection, including suggestions for reducing the burden, to the FAA at: 800 Independence Ave SW, Washington DC, 20591, Attn Information Collection Clearance Officer, ASP-110.
OMB Control Number 2120-0014
Exp. Date 8/31/2015

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)

Signature

Title

Electronic Version (Adobe)

NSN: 0052-00-895-4000