U.S. Department Of Transportation Federal Aviation Administration FAA Form 5280-1, Application for Airport Operating Certificate Paperwork Reduction Act Burden Statement A federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply with a collection of information subject to the requirements of the Paperwork Reduction Act unless that collection of information displays a currently valid OMB Control Number. The OMB Control Number for this information collection is 2120-0675. Public reporting for this collection of information, including development of an Airport Certification Manual or Airport Certification Specifications that must accompany this form, is estimated to be approximately 200 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, completing and reviewing the collection of information. All responses to this collection of information are mandatory under 14 CFR Part 139. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to the FAA at: 800 Independence Ave. SW, Washington, DC 20591, Attn: Information Collection Clearance Officer, ASP-110. American LegalNet, Inc. www.FormsWorkFlow.com OMB CONTROL NUMBER: 2120-0675 OMB EXPIRATION DATE: 7/31/2015 APPLICATION FOR AIRPORT OPERATING CERTIFICATE Department of Transportation FAA USE ONLY Site Number Federal Aviation Administration Complete all sections of the form as indicated. Submit original and three copies of the form and two copies of the Airport Certification Manual (ACM) to the headquarters of the appropriate FAA Regional Office. Type of Submission (Check One): Original 1. Name of Airport: 3. City: 7a. Latitude: 7b. Longitude: Amendment Exemption 2. Address (Number, Street, P.O. Box): 4. County: 8. Airport is: a. State Licensed b. State Inspected 5. State: 6. Zip Code: A. Location of Airport ° B. Ownership 1. ' " State County ° ' Military " Yes Yes No No 2. Airport is: Civil Mil/Civ Joint Use Shared Use Municipality Corporation Port Authority Other (Explain) 4. Name of Manager/Operator: Number/Street/P.O. Box: City: County: Airport Authority 3. Name of Owner: Number/Street/P.O. Box: City: County: C. Operative Data 1. Certificate Applied for: Class I Class II Class III Class IV State: Zip: State: Zip: 2. Fire Fighting Equipment (Check Current Index and ensure equipment is listed in ACM): A B C D E 4. Largest Air Carrier Aircraft to be Served (737, DC-9, etc.): 6. Other Exemptions Applied for: 3. Air Carriers to be Served (UA, DL, CO, AA, etc.): 5. ARFF Exemption Applied for: Yes D. Remarks. No Check here and use additional sheets of paper. E. Certification This application, including the Airport Certification Manual, is submitted in order to obtain an Airport Operating Certificate or Time-Limited Airport Operating Certificate. I certify, under penalty of 18 U.S. Code, Section 1001, and other applicable provisions of law that the statements and information in the application form and manual are complete and true to the best of my knowledge. Applicant Signature Applicant Address/Number/Street/P.O. Box: Applicant Name (typed): Applicant Title: Date Submitted: City: State: Zip: Telephone No.: FAA Use Only 1. Date Application Received: 3. Date Inspection Completed: 2. Date Proposed for Inspection: Signature Title : 4. Recommended for: Certificate Disapproval 5. Remarks Date: Signature Title : FAA Form 5280-1 (5/15) SUPERSEDES PREVIOUS EDITION American LegalNet, Inc. www.FormsWorkFlow.com