I. Pre-Inspection

1. Reviewed previous inspection?

1a. Outstanding items?

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

2. Reviewed Airport Master Record (5010 Form)?

2a. Airport Master Record changes?

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

3. Reviewed Airport Sketch?

3a. Airport Sketch changes?

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

4. Reviewed Airport Facility Directory?

4a. Airport Facility Directory changes?

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

5. Interviewed Sponsor Representitive?

5a. Interview items?

List any items that came out of the interview

5b. Wildlife Management Survey

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

If yes, when was it completed?

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

If yes, when was it completed?

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

If yes, when was it completed?

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

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

If yes, how high is the fence?

II. Runways

1. Length (changes will require completing category XII)

2. Width

3. Surface Condition

4. Pavement Edge

5. Runway Object Free Area / Primary Surface

6. Approach Surface (separate form is required)

7. Transitional Surface

8. Runway Protection Zone

9. Surface Gradient

10. Line of Sight

III. Taxiways

1. Width

2. Surface Condition

IV. Safety Areas

1. Dimensions Maintained

2. Ruts/Surface Variations

3. Drainage

4. Objects in Safety Area/Frangible Mounting

V. Markings, Signs and Lighting

1. Runway Markings

2. Taxiway Centerline

3. Taxiway Edge Markings

4. Holding Position Markings

5. Signs Identifying Taxiing Routes

6. Holding Position Signs

7. Signs Internally Illuminated

8. Runway Lighting/Reflectors

9. Taxiway Lighting/Reflectors

10. Airport Beacon

11. Obstruction Marking/Lighting

12. Markings/Signs/Lighting Properly Maintained

VI. Fuel Storage Areas

1. Fencing/Locks/Signs

2. Piping protected from vehicles

3. No Smoking signs posted

4. Deadman Controls for loading stations

5. Fire Extinguishers - Inspected/Accessible

6. Emergency Shutoff - Signed/Accessible

7. Fuel Leaks

8. Bonding wire/clips

9. Grounding

10. No vegetation or trash

11. No evidence of smoking

12. Fuel filters

VII. Mobile Fuelers

1. No Smoking sign in cab

2. Flammability signs/haz mat placards all sides

3. Bonding cables and clips

4. Deadman control

5. Fire Extinguishers - proper type/inspected

6. Emergency shutoffs operable and marked

7. Fuel leaks

8. Vehicle exhaust system - shielded

9. No evidence of smoking - no ashtray in cab

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

VIII. Traffic/Wind Indicators

1. Wind cones provided/condition

2. Segmented Circle

IX. Wildlife Observations

X. Miscellaneous Observations

XI. Sketches
Add 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?

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

1. Runway ID

2. Type of change

3. Date of change

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

Airport Representative
State Inspector