ISSUE OF AN AIRWORTHINESS REVIEW CERTIFICATE
(For ELA1 aircraft not used in commercial air transport or not affected by point M.A.201(i)) / LHD-1 ELA
Dags. 24.09.2013
1. APPLICATION
Owner/Holder wish to apply for
The issue of an Airworthiness Review Certificate based upon the certification and recommendation given in box 4.
Place the aircraft can be seen if required by ICETRA / Period
Name / Signature
E-mail / Mobile number
2. AIRCRAFT DETAILS
Registration / No. / Serial No.
Manufactur / Type
Engine
Manufactur / Type / Serial No(s)
Propeller
Manufactur / Type / Hub / Blade / Serial No.
Total aircraft hours / Total aircraft cycles
3. PART M, M.A.710 AIRWORTHINESS REVIEW COMPLIANCE STATEMENT
To be completed by the person completing the recommendation statement in box 4. If any of the items below cannot be confirmed, please
contact ICETRA Airworthiness Section.
(a) It is confirmed that to satisfy the requirement for an M.A.901 airworthiness review of an aircraft, a full documented review of the
aircraft records has been carried out so that we are satisfied as to the matters specified in M.A.710(a).
(b) A physical survey of the aircraft in accordance with M.A.710(c) has been satisfactorily completed.
(c) Place of document review / Date
(d) Place of physical survey / Date
(e) ICETRA ApprovedMaintenance Programme reference / Issue/amendment
(f) The aircraft complies with the latest revision of its type design approved by the agency (enter state of design)
(g) Aircraft TCDS / Revision/issue/edition number
(h) Aircraft Noise Certificate No. (if not applicable state N/A)
(Corresponding to the current configuration of the aircraft, and in compliance with Part-21, Subpart I)
(i) Flight Manual is applicable for the aircraft configuration. Flight Manual latest revision status
(j) The current mass and balance statement reflects the configuration of the aircraft and is valid
Mass& Balance Statement dated / Reference
(k) As part of the documented review as a minimum, the categories detailed in Part M, AMC M.A.710 (a) 1 have been sampled and found properly entered and certified in the aircraft continuing airworthiness records system.
(I) All applicable airworthiness directives have been applied and properly registered, up to: quote state, biweekly no. and issue date below
Aircraft State of Design Airworthiness Directives
Engine State of Design Airworthiness Directives
Propeller State of Design Airworthiness Directives
Equipment State of Design Airworthiness Directives
EASA Airworthiness Directives
4. Recommendation Statement for the issue of an Airworthiness Review Certificate.
Approved certifying staff as per M.A.901(g) recommendation statement
Pursuant to M.A. 901(g) of Annex 1 of Commission Regulation (EC) No 2042/2003, it is certified that the person below, being an approved person in accordance with M.A. 901(g), has performed an Airworthiness Review in accordance with M.A.710, and recommends that an Airworthiness Review Certificate be issued with a validity period of twelve months in respect of the aircraft identified in this document.
The Airworthiness Review Compliance Report is attached to this recommendation and a copy has been passed to the owner (holder) for retention in the aircraft records.
Airworthiness Report reference number / Recommendation date
Name of person making the recommendation
E-mail / Mobile number
Part 66 / Pilot Licence No. / IS.66. / Part 66 Licence valid until
M.A. 901(g) CS approval valid until / Approval reference
Signature
FOR ICETRA USE ONLY
5. Assessment of recommendation
Málsnúmer:
The Icelandic Transport Authority has:
Assessed and verified that the compliance statement contained in the recommendation demonstrates that a complete M.A.710 airworthiness review has been carried out
Issued an Airworthiness Review Certificate in accordance with point M.B.901 of Annex I to Commission Regulation (EC) No 2042/2003, as amended, in accordance with the recommendation above, valid from the issue date below in respect of the aircraft identified in this document.
It has been checked that ARC has not been issued for more than two consecutive years after recommendation made by certifying staff approved in accordance with M.A.901(g).
ARC Number / Issue Date / Expiry Date
Date / Signature / ARI No.
LHD-1 ELAPage 1 of 2Date 24.09.2013