Attachment 6- USCG Component Repair Record Samples.pdf

Attachment 6

U.S. COAST GUARD

COMPONENT REPAIR RECORD

THIS FORM IS USED TO REPORT MAINTENANCE ACTIONS PERFORMED ON COAST GUARD

COMPONENTS BY OVERHAUL/REPAIR FACILITIES.

PART NAME CEI NUMBER SERIAL NUMBER

PROPELLER 30-6100-001

PART NUMBER: 54H60-117 NSN:

THE COMPLETED FORM TO BE PROVIDED TO:

ORIGINAL TO: COPY 1:

ACMS - BLDG 78 PACKAGED WITH THE

USCG AVIATION LOGISTICS CENTER OVERHAULED/REPAIRED

ELIZABETH CITY, NC 27909-5001 COMPONENT

OVERHAUL/REPAIR FACILITY TO COMPLETE ALL INFORMATION IN DESIGNATED AREA

MANUFACTURER:

TSO: DATE OF MANUFACTURE:

HRS:

THE FOLLOWING NARRATIVE SUMMARIZES THE WORK PERFORMED ON THIS COMPONENT

DURING THE COURSE OF THIS OVERHAUL/REPAIR.

OVERHAUL/REPAIR FACILITY: WORK ORDER NO:

DATE WORK COMPLETED: ITEM BEYOND ECONOMICAL REPAIR: YES NO

THE FOLLOWING MAINTENANCE ACTIONS WERE COMPLIED WITH DURING THE COURSE OF

THIS OVERHAUL/REPAIR.

[ ] 611201 PROP FEATHER VALVE CHECK

[ ] 611101 PROP FEATHERING CHECK

[ ] 611300 PROP ASSY/COMPONENTS INSP/CHK

[ ] 611350 PROP BRUSH/SLIP RING INSP/CHK

[ ] 612021 PROP CONTROL LINKAGE INSP/CHK

[ ] 611001 PROPELLER BLADE ANGLE INSP/CHK

[ ] 611200 PROP SUPPLY/STAND-BY FLTR INSP/CLN

[ ] 610020 INVNTRY PROP SHIPMENT INSPECT

PROPELLER 30-6100-001

PART NUMBER: 54H60-117 NSN:

[ ] 610030 PROPELLER ASSEMBLY BUILDUP INSPECT

[ ] 961000 PROPS FOR ID OF S/N BLADE INSPECT

[ ] 610010 PROPELLER ASSEMBLY OVERHAUL

[ ] 611013 PROPELLER DOME SEAL REPLACE

[ ] 611044 PROP BALANCE NOT REQUIRED SERVICE

[ ] 611042 PROPELLER BALANCE SERVICE

[ ] 611033 PROPELLER OIL LEVEL SERVICE

[ ] 055055 PROPELLER (SUDDEN STOP) SPCL/INSP

AUTHORIZED SIGNATURE OR QUALITY ASSURANCE STAMP:

** FOR ACMS CONTRACTOR: DISENROLLED DATA ENTRY DATE **

PROPELLER BLADE 30-6110-001

PART NUMBER: NSN:

THE COMPLETED FORM TO BE PROVIDED TO:

ORIGINAL TO: COPY 1:

ACMS - BLDG 78 PACKAGED WITH THE

USCG AVIATION LOGISTICS CENTER OVERHAULED/REPAIRED

ELIZABETH CITY, NC 27909-5001 COMPONENT

OVERHAUL/REPAIR FACILITY TO COMPLETE ALL INFORMATION IN DESIGNATED AREA

MANUFACTURER:

TSO: DATE OF MANUFACTURE:

OVERHAUL/REPAIR FACILITY: WORK ORDER NO:

DATE WORK COMPLETED: ITEM BEYOND ECONOMICAL REPAIR: YES NO

[ ] 611000 PROPELLER BLADE OVERHAUL

[ ] 611030 BLADE RE-TWISTING SPCL/INSP

[ ] 611010 RE-COLD ROLLING/BLADE FILLET SPCL/INSP

[ ] 906134 REMOVAL TO OVHL. / SPCL/INSP. SPCL/INSP

[ ] 611020 TABERBORE CORROSION INSP. SPCL/INSP

VALVE HOUSING 30-6120-002

PART NUMBER: NSN:

THE COMPLETED FORM TO BE PROVIDED TO:

ORIGINAL TO: COPY 1:

ACMS - BLDG 78 PACKAGED WITH THE

USCG AVIATION LOGISTICS CENTER OVERHAULED/REPAIRED

ELIZABETH CITY, NC 27909-5001 COMPONENT

OVERHAUL/REPAIR FACILITY TO COMPLETE ALL INFORMATION IN DESIGNATED AREA

MANUFACTURER:

TSO: DATE OF MANUFACTURE:

OVERHAUL/REPAIR FACILITY: WORK ORDER NO:

DATE WORK COMPLETED: ITEM BEYOND ECONOMICAL REPAIR: YES NO

[ ] 961010 VALVE HOUSING FILTER INSPECT

[ ] 612110 VALVE HOUSING OVERHAUL

PUMP HOUSING 30-6120-001

PART NUMBER: NSN:

THE COMPLETED FORM TO BE PROVIDED TO:

ORIGINAL TO: COPY 1:

ACMS - BLDG 78 PACKAGED WITH THE

USCG AVIATION LOGISTICS CENTER OVERHAULED/REPAIRED

ELIZABETH CITY, NC 27909-5001 COMPONENT

OVERHAUL/REPAIR FACILITY TO COMPLETE ALL INFORMATION IN DESIGNATED AREA

MANUFACTURER:

TSO: DATE OF MANUFACTURE:

OVERHAUL/REPAIR FACILITY: WORK ORDER NO:

DATE WORK COMPLETED: ITEM BEYOND ECONOMICAL REPAIR: YES NO

[ ] 612060 PUMP HOUSING OVERHAUL