Form PPQ 816 PPQ 816 Contract Pilot and Aircraft Acceptance

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of
information unless it displays a valid OMB control number. The OMB control number for this information collection is 0579-0298. The time required
to complete this information collection is estimated to average .25 hours per response, including the time for reviewing instructions, searching existing
data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.
1. PROGRAM

UNITED STATES DEPARTMENT OF AGRICULTURE
ANIMAL AND PLANT HEALTH INSPECTION SERVICEPLANT
PROTECTION AND QUARANTINE

OMB Approved
0579-0298
EXP. XX/XXXX

2. REGION
4. CONTRACT NUMBER

3. INSPECTION SITE
5. DATE

CONTRACT PILOT AND AIRCRAFT ACCEPTANCE
6. CONTRACTOR’S NAME AND MAILING ADDRESS (including ZIP Code)

7. REGISTERED AIRCRAFT OWNER’S NAME AND MAILING ADDRESS (including ZIP Code)

TELEPHONE NUMBER

TELEPHONE NUMBER

8. STATE APPLICATOR BUSINESS LICENSE AND EXPIRATION DATE

9. FAA AG CERTIFICATE NUMBER

10. CONGESTED AREA WAIVER (If required)
YES

PILOT INFORMATION

NO

NA

NOTE: FOR OBSERVATION PILOT COMPLETE BLOCKS 11-20 ONLY

11. PILOT’S NAME AND MAILING ADDRESS (including ZIP Code)

16. GOVERNMENT ISSUED PHOTO ID
(Passport, Driver’s License)

YES

NO

17. TOTAL TIME
______________________ (1,000 Hours Minimum)
18. TOTAL PIC TIME IN TYPE (i.e., AT-301; C-182)
______________________ (25 Hours Minimum)
TELEPHONE NUMBER

19. TOTAL AG AND/OR OBSERVATION TIME
(Observation Pilot)
______________________ (50 Hours Minimum)

12. CERTIFICATE AND NUMBER (ATP or Commercial)

20. OBSERVATION PILOT/APPLICATOR LETTER OF COMPETENCY
13. RATINGS

YES

NO

21. TOTAL AG TIME
14. MEDICAL CLASS/DATE

______________________ (100 Hours Minimum)
22. STATE OF ISSUE, APPLICATOR LICENSE NUMBER AND EXPIRATION DATE

15. FLIGHT REVIEW DATE

AIRCRAFT INFORMATION

NOTE: FOR OBSERVATION AIRCRAFT COMPLETE BLOCKS 23-30 ONLY

23. AIRCRAFT REGISTRATION NUMBER

28. PROOF OF INSURANCE

N

YES

24. AIRCRAFT MAKE/MODEL

29. SPEED (MPH)

33. RATE/ACRE

25. DATE OF ANNUAL INSPECTION

30. DATE AVAILABLE

34. ASSIGNED SWATH

26. AIRCRAFT TIME SINCE 100-HOUR INSPECTION

31. CATEGORY

35. GUIDANCE TYPE

27. AIRWORTHINESS CERTIFICATE CATEGORY

32. CHEMICAL

C

NO

D
Precision DGPS Make ___________________
Non-precision (flagging, kytoons, etc.) _____________

APPLICATION SYSTEMS
DRY
36. SPREADER
MAKE _____________________

39. AIR AGITATION, RAM AIR INTAKE, AND VENT TUBE FLOW REGULATOR INSTALLED
PROPERLY
MODEL_____________________

37. SPREADER CLEAN AND FREE OF CONTAMINATION

YES
40. SPECIAL EQUIPMENT REQUIRED (flagman, smoker, etc.)

YES
NO
38. HOPPER INTERIOR CLEAN/DRY AND INTERNAL VALVES SEALED

41. EQUIPPED WITH JETTISON DEVICE THAT MEETS CFR PART 137.53(C)(2)

YES

PPQ Form 816
SEP 2015

NO

YES

NO

NO

APPLICATION SYSTEMS (continued)
LIQUID

YES

NO

42. HOPPER/SPRAY TANK INTERIOR DRY AND CLEANED OF ALL CONTAMINATION
43. LEAK PROOF--CHECK CONDITION OF HOSES, GATE SEAL, AND OTHER SPRAY SYSTEM COMPONENTS
44. EQUIPPED WITH JETTISON DEVICE THAT MEETS CFR PART 137.53(C)(2)
45. DRAIN VALVE(S) LOCATED AT LOWEST POINT(S) IN THE SYSTEM
46. EMERGENCY SHUT-OFF VALVE LOCATED BETWEEN THE HOPPER AND PUMP (ASK FOR A DEMONSTRATION)
47. BLEED LINES INSTALLED ON SPRAY BOOMS WHEN REQUIRED (SEE STATEMENT OF WORK FOR CORRECT INSTALLATION OF BLEED LINES)
48. PUMP HAS CAPACITY TO DELIVER 40 PSI TO ALL SPRAY NOZZLES
49. FUNCTIONAL PRESSURE GAUGE WITH A MINIMUM RANGE OF ZERO TO 60, BUT NO GREATER THAN ZERO TO 100 PSI
50. IN-LINE STRAINER BETWEEN PUMP AND BOOM
51. UNUSED NOZZLES REMOVED AND OPENINGS PLUGGED
52. SPECIAL EQUIPMENT REQUIRED (I.E., FLAGMAN, SMOKER, ETC.) IF YES, THEN SPECIFY
53. METHOD TO DETERMINE THE AMOUNT OF CHEMICAL IN THE HOPPER, IN FLIGHT, AND ON THE GROUND
54. NUMBER OF NOZZLES INSTALLED
FOR APPLICATION

55. SPRAY TIP AND STRAINER SIZE (I.E., SS8002/50 MESH (SEE STATEMENT OF
WORK FOR SPECIFIC AIRCRAFT TIP AND SIZE)

56. OPERATING BOOM PRESSURE (PSI)

DEFICIENCIES NOTED

DEFICIENCIES CORRECTED

REMARKS

CERTIFICATION
I certify that I have completed the above inspections and have noted findings as

ACCEPTABLE

UNACCEPTABLE

57. OFFICIAL SIGNATURE

TITLE

DATE

58. PILOT/CONTRACTOR SIGNATURE

TITLE

DATE

PPQ Form 816 (Reverse)
SEP 2015