Piper Cherokee Archer II Pilot Operating Handbook page 110

(8320)
OF TRANSPORT INSPECTOR
OF AIRCRAFT
SIGNATURE OF
REPAIR STATION
. CERTIFICATE OR
DESIGNATION NO.
OOA SO-l
FAA DESIGNEE
oJAIE Of
APPROVAL
'OR
REJECTION
JAN 2 7 lS]a
~lt.lt.
t=nnn
:1:17
/7_67\
DEPARTMENT OF TRANSPORTATION
Form
ApprolJ~d
FEDERAL AVIATION ADMINISTRATION
Budget Bure,m No. 04-R060. I
MAJOR REPAIR AND ALTERATION
FOR FAA USE ONU'
(Airframe, Powerplant, Propeller, or Appliance)
OFFICE IDENTIFICATION
--
:NSTRUCTIONS: Print or type all entries. See FAR 43.9, FAR 43 Appendix B, and AC 43.9-1 (or subsequent revision thereof)
for insuucdons and disposition of this form.
MAKE MODEl
1. AIRCRAFT
Piper
PA28-181
SERIAL NO. NATIONALITY AND REGISTRATION MARK
28-7890340
LN-NFQ
NAME (As shown on
registration cerlir,cate)
ADDRESS
(As shown
on registration
cerlificate)
2. OWNER
P.O. Box 1328
Piper Aircraft Corporation Vero Beach, Florida 32960
. 3.
FOR FAA USE ONLY
I
4.
UNIT IDENTIFICATION
S. TYPE
UNIT MAKE MODel SERIAL NO.
AlTER-
REPAIR
All ON
AIRFRAME
##""###"""",.,,.
(As
described
in
item
1
above)"""""""""""
X
POWERPLANT
-~
~._~-
- - - - -
PROPELLER
TY.fE
APPLIANCE
MANUFACTURER
6. CONFORMITY S!ATEMENT
A. AGENCY'S NAME AND ADDRESS B. KIND OF AGENCY
C. CERTIFICATE NO.
--
----~_._~--._~._--- -~~ ---_.~-----. ----~".
------------
-- -
-~
U.S. CERTlFICATED MECHANIC
Piper Aircraft Corporation
FOREIGN CERTIFICATED MECHANIC
P.O. Box 1328
CERTIFICATED REPAIR STATION
FAA DOA 00-1
Vera Beach, Florida 32960
x
MANUFACTURER
D. I
~ertjfy
that the repair and/or alteration made
to
the unit(s) idt:mified in item 4 above and described on the revt:rse or
attachments hereto have been made in accordance with the requifemems of Part 43 of the
u.s.
Federal Aviation Regulatiom
and that the information furnished herein is true and correct to the best of my knowledge.
DATE SIGNATURE OF AUTHORIZED INDIVIDUAL
JAil 2 7
19111
/:L{.{~/.,
j.J.J
{I"r/I),:-rf-
7.
APPROVAU()~RETjJJl~
T()SERVICE
._--
Pursuant
to
the authority given persons specified below, the unit identified in item 4
W.iS
inspectt::J in the manner prescribed by
the Administrator of the Federal Aviation Administration and is :
~
APPROVED
0
REJECTED
FAA FlY. STANDARDS
:x
OTHER '(5ptKify)
MANUFACTURER
INSPECTlON AUTHORIZATION
INSPECTOR
BY
CANADIAN DEPARTMENT
,
(-