State of Nevada Airport Inspection

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

I. Pre-Inspection

• 1. Reviewed previous inspection?

  Yes

  No

  N/A

• 1a. Outstanding items?

  No

  Yes

• List all outstanding items from previous inspections (describe mitigation a and time frames that will be used)

• 2. Reviewed Airport Master Record (5010 Form)?

  Yes

  No

  N/A

• 2a. Airport Master Record changes?

  No

  Yes

• List of changes to Airport Master Record (list changes by category and item numbers, give regulation or circular if applicable)

• 3. Reviewed Airport Sketch?

  Yes

  No

  N/A

• 3a. Airport Sketch changes?

  No

  Yes

• Describe changes to Airport Sketch (copy of marked up sketch will be sent separately)

• 4. Reviewed Airport Facility Directory?

  Yes

  No

  N/A

• 4a. Airport Facility Directory changes?

  No

  Yes

• List changes or additions that need to be made to the Airport Facility Directory

• 5. Interviewed Sponsor Representitive?

  Yes

  No

  N/A

• 5a. Interview items?

  No

  Yes

• List any items that came out of the interview

• 5b. Wildlife Management Survey

  Yes

  No

• 5b-1. Does your airport have a Wildlife Site Visit?

  Yes

  No

• If yes, when was it completed?

  Date

• 5b-2. Does your airport have a Wildlife Hazard Assessment?

  Yes

  No

• If yes, when was it completed?

  Date

• 5b-3. Does your airport have a Wildlife Hazard Management Plan?

  Yes

  No

• If yes, when was it completed?

  Date

• 5b-4. Do you have a state wildlife depredation permit?

  Yes

  No

• 5b-5. Does your airport have fencing around the airport?

  Yes

  No

• If yes, how high is the fence?

II. Runways

• 1. Length (changes will require completing category XII)

  Safe

  At Risk

  N/A

• 2. Width

  Safe

  At Risk

  N/A

• 3. Surface Condition

  Safe

  At Risk

  N/A

• 4. Pavement Edge

  Safe

  At Risk

  N/A

• 5. Runway Object Free Area / Primary Surface

  Safe

  At Risk

  N/A

• 6. Approach Surface (separate form is required)

  Safe

  At Risk

  N/A

• 7. Transitional Surface

  Safe

  At Risk

  N/A

• 8. Runway Protection Zone

  Safe

  At Risk

  N/A

• 9. Surface Gradient

  Safe

  At Risk

  N/A

• 10. Line of Sight

  Safe

  At Risk

  N/A

III. Taxiways

• 1. Width

  Safe

  At Risk

  N/A

• 2. Surface Condition

  Safe

  At Risk

  N/A

IV. Safety Areas

• 1. Dimensions Maintained

  Safe

  At Risk

  N/A

• 2. Ruts/Surface Variations

  Safe

  At Risk

  N/A

• 3. Drainage

  Safe

  At Risk

  N/A

• 4. Objects in Safety Area/Frangible Mounting

  Safe

  At Risk

  N/A

V. Markings, Signs and Lighting

• 1. Runway Markings

  Safe

  At Risk

  N/A

• 2. Taxiway Centerline

  Safe

  At Risk

  N/A

• 3. Taxiway Edge Markings

  Safe

  At Risk

  N/A

• 4. Holding Position Markings

  Safe

  At Risk

  N/A

• 5. Signs Identifying Taxiing Routes

  Safe

  At Risk

  N/A

• 6. Holding Position Signs

  Safe

  At Risk

  N/A

• 7. Signs Internally Illuminated

  Safe

  At Risk

  N/A

• 8. Runway Lighting/Reflectors

  Safe

  At Risk

  N/A

• 9. Taxiway Lighting/Reflectors

  Safe

  At Risk

  N/A

• 10. Airport Beacon

  Safe

  At Risk

  N/A

• 11. Obstruction Marking/Lighting

  Safe

  At Risk

  N/A

• 12. Markings/Signs/Lighting Properly Maintained

  Safe

  At Risk

  N/A

VI. Fuel Storage Areas

• 1. Fencing/Locks/Signs

  Safe

  At Risk

  N/A

• 2. Piping protected from vehicles

  Safe

  At Risk

  N/A

• 3. No Smoking signs posted

  Safe

  At Risk

  N/A

• 4. Deadman Controls for loading stations

  Safe

  At Risk

  N/A

• 5. Fire Extinguishers - Inspected/Accessible

  Safe

  At Risk

  N/A

• 6. Emergency Shutoff - Signed/Accessible

  Safe

  At Risk

  N/A

• 7. Fuel Leaks

  Safe

  At Risk

  N/A

• 8. Bonding wire/clips

  Safe

  At Risk

  N/A

• 9. Grounding

  Safe

  At Risk

  N/A

• 10. No vegetation or trash

  Safe

  At Risk

  N/A

• 11. No evidence of smoking

  Safe

  At Risk

  N/A

• 12. Fuel filters

  Safe

  At Risk

  N/A

VII. Mobile Fuelers

• 1. No Smoking sign in cab

  Safe

  At Risk

  N/A

• 2. Flammability signs/haz mat placards all sides

  Safe

  At Risk

  N/A

• 3. Bonding cables and clips

  Safe

  At Risk

  N/A

• 4. Deadman control

  Safe

  At Risk

  N/A

• 5. Fire Extinguishers - proper type/inspected

  Safe

  At Risk

  N/A

• 6. Emergency shutoffs operable and marked

  Safe

  At Risk

  N/A

• 7. Fuel leaks

  Safe

  At Risk

  N/A

• 8. Vehicle exhaust system - shielded

  Safe

  At Risk

  N/A

• 9. No evidence of smoking - no ashtray in cab

  Safe

  At Risk

  N/A

• 10. Vehicle parking - 10' apart/50' from buildings - on pavement

  Safe

  At Risk

  N/A

VIII. Traffic/Wind Indicators

• 1. Wind cones provided/condition

  Safe

  At Risk

  N/A

• 2. Segmented Circle

  Safe

  At Risk

  N/A

IX. Wildlife Observations

X. Miscellaneous Observations

XI. Sketches

• Add drawing

  Drawing

XII. Runway Length Change (required if there was a change in the runway length or displaced threshold)

• Was there a change in the length/direction of a runway or displaced threshold?

  No

  Yes

• Note: Horizontal DATUM should be NAD83 / Vertical DATUM should be NAVD88

• 1. Runway ID

• 2. Type of change

• 3. Date of change

  Date

• 4. Old runway length

• 5. New runway length

• 6. Distance runway extended or shortened/Direction

• 7. Runway width

• 8. Runway end changed

• 9. New Latitude and Longitude

• 10. New runway end elevation

• 11. New runway touch down zone elevation (highest elevation in the first 3,000 feet)

• 12. New runway azimuths (true)

• 13. Displaced threshold length

• 14. Displaced threshold width

• 15. Displaced threshold Latitude and Longitude

• 16. Displaced threshold elevation

• 17. Change to ARP Latitude and Longitude (if appropriate)

• 18. Additional information

Signatures

• Airport Representative

  Sign

• State Inspector

  Sign