FAR 139 ACSI

• Audit Title

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

ACSI Review

• FAA Form 5010-1 Update/Review<br>

  Yes

  No

  N/A

• Obstruction Chart Review

  Yes

  No

  N/A

• ACM / ACS Review (201)<br>

  Yes

  No

  N/A

• Review Self Inspection Records and Procedures for Corrective Action (327)

  Yes

  No

  N/A

• Review of NOTAM Records and Procedures (339)

  Yes

  No

  N/A

• Movement Area Inspection (Daylight) (311)<br>

  Yes

  No

  N/A

• Movement Are Inspection (Night) (311)<br>

  Yes

  No

  N/A

• Perimeter Fence Inspection (335)<br>

  Yes

  No

  N/A

• Solicit Comments From Local Coordinator

  Yes

  No

  N/A

• ARFF Response Drill (Day-light) (319)<br>

  Yes

  No

  N/A

• ARFF Response Drill (Night) (319)<br>

  Yes

  No

  N/A

• Fuel Farm and Fueling Vehicle Inspection (321)<br>

  Yes

  No

  N/A

• Airport Layout Plan Review<br>

  Yes

  No

  N/A

• Lease/Use Agreement Review

  Yes

  No

  N/A

ARFF Station

• Personnel Training Records (319)<br>

  Yes

  No

  N/A

• Vehicle Maintenance Records (319)

  Yes

  No

  N/A

• Refractometer Test / Records (319)<br>

  Yes

  No

  N/A

• Emergency Plan (325)<br>

  Yes

  No

  N/A

Exit Interview

• Discussion of Federal Agreement Compliance Issues

  Yes

  No

  N/A

• Discussion of Deficiencies / Violations Observed<br>

  Yes

  No

  N/A

• Establish Corrective Action Suspense Dates<br>

  Yes

  No

  N/A

• Discussion of Safety Related Issues or Recommendations

  Yes

  No

  N/A

• Discussion of ATCT and Other FAA Issues or Recommendations<br>

  Yes

  No

  N/A

Other Items

• Items

• Photo(s)

  Media

Name & Rank of Inspector

• Name & Rank of inspector

  Sign

• Date & Time of Inspection

  Date