Attachment 3 - PPQ Form 816.pdf
PDF 206 KB Posted
- Attached to
- Grasshopper Aerial Pesticide Aerial Application
- Solicitation number
- 12639526Q0179
About this file
This is a Contract Pilot and Aircraft Acceptance form (PPQ Form 816) issued by the United States Department of Agriculture's Animal and Plant Health Inspection Service, Plant Protection and Quarantine division. The form serves as an inspection and certification document for agricultural aircraft and pilots involved in federal pesticide application contracts. The form is designed to document compliance with federal aviation and agricultural chemical application regulations prior to contract authorization.
The form contains three primary sections: general contract information (program, region, inspection site, contract number, contractor details, and registered aircraft owner information); pilot information requirements including certification standards such as minimum flight hours (1,000 total hours, 25 hours in aircraft type, 50 hours observation minimum, and 100 hours agricultural application minimum), medical certification, and flight review dates; and aircraft information requirements including registration, maintenance records (annual inspection and 100-hour inspection status), airworthiness certification, and equipment specifications. For dry application systems, the form requires verification of spreader cleanliness, proper air agitation installation, and jettison device compliance with CFR Part 137.53(c)(2). For liquid application systems, inspectors must verify hopper integrity, leak-proof conditions, emergency shut-off valves, pressure gauges (0-60 to 0-100 PSI range), in-line strainers, nozzle specifications, and operating boom pressure documentation. The form culminates in a certification section where an official inspector and the pilot/contractor sign to indicate whether findings are acceptable or unacceptable, with space for documenting any deficiencies noted and corrective actions taken.
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Text version
According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control number. The OMB control number for this information collection is 0579-0298. The time required to complete this information collection is estimated to average .25 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.
OMB Approved 0579-0298
EXP. 08/2026
UNITED STATES DEPARTMENT OF AGRICULTURE
ANIMAL AND PLANT HEALTH INSPECTION SERVICEPLANT
PROTECTION AND QUARANTINE
CONTRACT PILOT AND AIRCRAFT ACCEPTANCE
1. PROGRAM
3. INSPECTION SITE
2. REGION
4. CONTRACT NUMBER
5. DATE
6. CONTRACTOR’S NAME AND MAILING ADDRESS (including ZIP Code) 7. REGISTERED AIRCRAFT OWNER’S NAME AND MAILING ADDRESS (including ZIP Code)
TELEPHONE NUMBER TELEPHONE NUMBER
8. STATE APPLICATOR BUSINESS LICENSE AND EXPIRATION DATE 9. FAA AG CERTIFICATE NUMBER 10. CONGESTED AREA WAIVER (If required)
YES NO NA
PILOT INFORMATION NOTE: FOR OBSERVATION PILOT COMPLETE BLOCKS 11-20 ONLY
11. PILOT’S NAME AND MAILING ADDRESS (including ZIP Code) 16. GOVERNMENT ISSUED PHOTO ID
(Passport, Driver’s License) YES NO
17. TOTAL TIME
______________________ (1,000 Hours Minimum)
18. TOTAL PIC TIME IN TYPE (i.e., AT-301; C-182)
______________________ (25 Hours Minimum)
TELEPHONE NUMBER 19. TOTAL AG AND/OR OBSERVATION TIME
(Observation Pilot)
______________________ (50 Hours Minimum) 12. CERTIFICATE AND NUMBER (ATP or Commercial)
20. OBSERVATION PILOT/APPLICATOR LETTER OF COMPETENCY
YES NO13. RATINGS
21. TOTAL AG TIME
______________________ (100 Hours Minimum) 14. MEDICAL CLASS/DATE
22. STATE OF ISSUE, APPLICATOR LICENSE NUMBER AND EXPIRATION DATE
15. FLIGHT REVIEW DATE
AIRCRAFT INFORMATION NOTE: FOR OBSERVATION AIRCRAFT COMPLETE BLOCKS 23-30 ONLY
23. AIRCRAFT REGISTRATION NUMBER
N
28. PROOF OF INSURANCE
YES NO
24. AIRCRAFT MAKE/MODEL 29. SPEED (MPH) 33. RATE/ACRE
25. DATE OF ANNUAL INSPECTION 30. DATE AVAILABLE 34. ASSIGNED SWATH
26. AIRCRAFT TIME SINCE 100-HOUR INSPECTION 31. CATEGORY
C D
35. GUIDANCE TYPE
Precision DGPS Make ___________________
Non-precision (flagging, kytoons, etc.) _____________
27. AIRWORTHINESS CERTIFICATE CATEGORY 32. CHEMICAL
APPLICATION SYSTEMS
DRY
36. SPREADER
MAKE _____________________ MODEL_____________________
39. AIR AGITATION, RAM AIR INTAKE, AND VENT TUBE FLOW REGULATOR INSTALLED
PROPERLY
YES NO
37. SPREADER CLEAN AND FREE OF CONTAMINATION
YES NO
40. SPECIAL EQUIPMENT REQUIRED (flagman, smoker, etc.)
38. HOPPER INTERIOR CLEAN/DRY AND INTERNAL VALVES SEALED
YES NO
41. EQUIPPED WITH JETTISON DEVICE THAT MEETS CFR PART 137.53(C)(2)
YES NO
PPQ Form 816
SEP 2015
APPLICATION SYSTEMS (continued)
LIQUID YES NO
42. HOPPER/SPRAY TANK INTERIOR DRY AND CLEANED OF ALL CONTAMINATION
43. LEAK PROOF--CHECK CONDITION OF HOSES, GATE SEAL, AND OTHER SPRAY SYSTEM COMPONENTS
44. EQUIPPED WITH JETTISON DEVICE THAT MEETS CFR PART 137.53(C)(2)
45. DRAIN VALVE(S) LOCATED AT LOWEST POINT(S) IN THE SYSTEM
46. EMERGENCY SHUT-OFF VALVE LOCATED BETWEEN THE HOPPER AND PUMP (ASK FOR A DEMONSTRATION)
47. BLEED LINES INSTALLED ON SPRAY BOOMS WHEN REQUIRED (SEE STATEMENT OF WORK FOR CORRECT INSTALLATION OF BLEED LINES)
48. PUMP HAS CAPACITY TO DELIVER 40 PSI TO ALL SPRAY NOZZLES
49. FUNCTIONAL PRESSURE GAUGE WITH A MINIMUM RANGE OF ZERO TO 60, BUT NO GREATER THAN ZERO TO 100 PSI
50. IN-LINE STRAINER BETWEEN PUMP AND BOOM
51. UNUSED NOZZLES REMOVED AND OPENINGS PLUGGED
52. SPECIAL EQUIPMENT REQUIRED (I.E., FLAGMAN, SMOKER, ETC.) IF YES, THEN SPECIFY
53. METHOD TO DETERMINE THE AMOUNT OF CHEMICAL IN THE HOPPER, IN FLIGHT, AND ON THE GROUND
54. NUMBER OF NOZZLES INSTALLED
FOR APPLICATION
55. SPRAY TIP AND STRAINER SIZE (I.E., SS8002/50 MESH (SEE STATEMENT OF
WORK FOR SPECIFIC AIRCRAFT TIP AND SIZE)
56. OPERATING BOOM PRESSURE (PSI)
DEFICIENCIES NOTED
DEFICIENCIES CORRECTED
REMARKS
CERTIFICATION
I certify that I have completed the above inspections and have noted findings as ACCEPTABLE UNACCEPTABLE
57. OFFICIAL SIGNATURE TITLE DATE
58. PILOT/CONTRACTOR SIGNATURE TITLE DATE
PPQ Form 816 (Reverse)
SEP 2015
| 10 CONGESTED AREA WAIVER If required: Off |
| undefined: Off |
| 20 OBSERVATION PILOTAPPLICATOR LETTER OF COMPETENCY: Off |
| 100 Hours Minimum: |
| 14 MEDICAL CLASSDATE: |
| 15 FLIGHT REVIEW DATE: |
| 22 STATE OF ISSUE APPLICATOR LICENSE NUMBER AND EXPIRATION DATE: |
| 23 AIRCRAFT REGISTRATION NUMBER N: |
| undefined_2: Off |
| 24 AIRCRAFT MAKEMODEL: |
| 29 SPEED MPH: |
| 33 RATEACRE: |
| 25 DATE OF ANNUAL INSPECTION: |
| 30 DATE AVAILABLE: |
| 34 ASSIGNED SWATH: |
| 26 AIRCRAFT TIME SINCE 100HOUR INSPECTION: |
| C: Off |
| D: Off |
| Precision DGPS Make: |
| 27 AIRWORTHINESS CERTIFICATE CATEGORY: |
| 32 CHEMICAL: |
| Nonprecision flagging kytoons etc: |
| MODEL: |
| undefined_3: |
| 39 AIR AGITATION RAM AIR INTAKE AND VENT TUBE FLOW REGULATOR INSTALLED: Off |
| 37 SPREADER CLEAN AND FREE OF CONTAMINATION: Off |
| 40 SPECIAL EQUIPMENT REQUIRED flagman smoker etc: |
| 38 HOPPER INTERIOR CLEANDRY AND INTERNAL VALVES SEALED: Off |
| 54 NUMBER OF NOZZLES INSTALLED FOR APPLICATION: |
| 55 SPRAY TIP AND STRAINER SIZE IE SS800250 MESH SEE STATEMENT OF WORK FOR SPECIFIC AIRCRAFT TIP AND SIZE: |
| 56 OPERATING BOOM PRESSURE PSI: |
| DEFICIENCIES NOTED 1: |
| DEFICIENCIES NOTED 2: |
| DEFICIENCIES NOTED 3: |
| DEFICIENCIES NOTED 4: |
| DEFICIENCIES NOTED 5: |
| DEFICIENCIES NOTED 6: |
| 1: |
| 2: |
| 3: |
| 4: |
| 5: |
| 6: |
| 1_2: |
| 2_2: |
| 3_2: |
| 4_2: |
| 5_2: |
| 6_2: |
| TITLE: |
| DATE: |
| TITLE_2: |
| DATE_2: |
| TELEPHONE NUMBER_3: |
| 50 Hours Minimum: |
| 12 CERTIFICATE AND NUMBER ATP or Commercial: |
| 13 RATINGS: |
| 1 PROGRAM: |
| 3 INSPECTION SITE: |
| 7 REGISTERED AIRCRAFT OWNERS NAME AND MAILING ADDRESS including ZIP Code: |
| TELEPHONE NUMBER_2: |
| 9 FAA AG CERTIFICATE NUMBER: |
| 2 REGION: |
| 4 CONTRACT NUMBER: |
| 5 DATE: |
| 6 CONTRACTORS NAME AND MAILING ADDRESS including ZIP Code: |
| TELEPHONE NUMBER: |
| 8 STATE APPLICATOR BUSINESS LICENSE AND EXPIRATION DATE: |
| 11 PILOTS NAME AND MAILING ADDRESS including ZIP Code: |
| 1000 Hours Minimum: |
| 25 Hours Minimum: |
| 42: |
| Hopper/Spray Tank Interior Dry and Cleaned of all contamination: Off |
| 43: |
| leak Proof-Check condition of hoses, gate seal, and other Spray System Components: Off |
| 44: |
| Equipped with Jettison device that meets CFR Part 137: |
| 53(c)(2): Off |
| 45: |
| Drain Valve(s) located at lowest point(s) in the system: Off |
| 46: |
| emergency shut-off valve located between the hopper and pump (ask for demonstration): Off |
| 47: |
| Bleed lines installed on spray booms when requires (see statement of work for correct installation of bleed lines): Off |
| 48: |
| Pump has capacity to deliver 40 PSI to all spray nozzles: Off |
| 49: |
| Functional pressure gauge with a minimum range of zero to 60, but no greater than zero to 100 PSI: Off |
| 50: |
| In-line strainer between pump and boom: Off |
| 51: |
| Unused Nozzles removed and openings plugged: Off |
| 52: |
| Special equipment required (i: |
| e: |
| , Flagman, Smoker, etc: |
| ) Yes then specify: Off |
| 53: |
| Method to determine the amount of chemical in the hopper, in flight, and on the ground: Off |
57:
58:
Certification: Off
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