5500-1 Attachment G

OMB Control Number: 2120-0557

Paperwork Reduction Act 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 2120-0557. Public reporting for this collection of information is estimated to be approximately 51 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. All responses to this collection of information are required to obtain FAA approval of authority to collect PFC revenue (49 U.S.C. 40117(h)). Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: Information Collection Clearance Officer, Federal Aviation Administration, 10101 Hillwood Parkway, Fort Worth, TX 76177-1524.

Expiration Date: 11/30/2024

Instructions: The information that a public agency must file when applying for authority to impose a PFC and for authority to use PFC revenue on a project is specified in 14 CFR Part 158. In accordance with section 158.25, a public agency that chooses to apply for authority to impose a PFC and for authority to use PFC revenue on a project must do so by using FAA Form 5500-1, PFC Application (latest edition) and all applicable attachments. Public agencies may use this Attachment B template for all FAA Form 5500-1 submissions if the applicable regulation requires the submission of project information in addition to the form.

Note: Public agencies seeking PFC authorization under the FAA’s Notice of Intent review process may use the Attachment H template to provide project information.

FORM 5500-1, ATTACHMENT G

AIRPORT LAYOUT PLAN (ALP), AIRSPACE, AND ENVIRONMENTAL FINDINGS

ALL PROJECTS FOR WHICH IMPOSE AND USE OR USE AUTHORITY IS REQUESTED IN THE APPLICATION MUST BE LISTED UNDER EACH TYPE OF FINDING BELOW.

*****FOR FAA USE*********************************************************************************************

PFC Application Number:

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1. ALP Findings

1. Current ALP approval date:

List proposed project(s) shown on this ALP:

2. List proposed project(s) not required to be shown on an ALP:

*****FOR FAA USE**********************************************************************************************

Public agency information confirmed? YES [ ] PARTIALLY [ ] NO [ ]

For each project which the ADO/RO disagrees with the public agency’s finding, discuss the reason(s) for the FAA’s nonconcurrance below.

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2. Airspace Findings

1. FAA Airspace finding date: __________________ (repeat as necessary)

List proposed project(s) covered by this finding:

2. List proposed project(s) not required to have an airspace determination

*****FOR FAA USE**********************************************************************************************

Public agency information confirmed? YES [ ] PARTIALLY [ ] NO [ ]

For each project which the ADO/RO disagrees with the public agency’s finding, discuss the reason(s) for the FAA’s nonconcurrance below.

*******************************************************************************************************************

3. Environmental Findings

1. List proposed project(s) which are categorically excluded from the requirement for formal environmental review:

2. Date of FAA Finding of No Significant Impact: _______________

(repeat as necessary)

List proposed project(s) covered by this finding:

3. Date of FAA environmental record of decision: ________________

(repeat as necessary)

List proposed project(s) covered by this finding:

*****FOR FAA USE*********************************************************************************************

Public agency information confirmed? YES [ ] PARTIALLY [ ] NO [ ]

For each project which the ADO/RO disagrees with the public agency’s finding, discuss the reason(s) for the FAA’s nonconcurrance below.

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Application Reviewed by:

____________________________ ____________________ _________________

Name Routing Symbol Date

1/2022