Attachment G Request for Waiver to Airfield and Airspace Criteria Form.pdf

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REQUEST FOR WAIVER TO AIRFIELD AND AIRSPACE CRITERIA

TO BE COMPLETED BY THE BASE CIVIL ENGINEER

TO:

FROM:

DATE (YYYYMMDD)

HQ USAFE/A7P

UNIT 3050 BOX 10

APO AE 09094-5010

1. ACTION REQUESTED

TEMPORARY WAIVER

PERMANENT WAIVER

CANCELLATION OF WAIVER

OTHER

4. DATES (YYYYMMDD) FOR TEMPORARY WAIVER

2. WAIVER NUMBER

3. DESCRIPTION

FROM

TO

5. FISCAL YEAR AND FUNDING SOURCE

6. PROJECT NUMBER

7. PROJECT TITLE

8. CRITERIA TO BE WAIVED (State chapter, paragraph, table number, etc.)

USAFEI 32-1007

OTHER

HOST CRITERIA

9. DESCRIPTION OF THE PROPOSED FACILITY* (Specify how the proposed facility violates criteria. Include information on the size of the facility (length, width, height, diameter, etc.), type of construction (materials, permanency, etc.), and degree of frangibility, grid location and applicable Tab E map numbers. Attach a location plan and site plan. The site plan will show all existing waivers in the project area, elevations at the location of the proposed facility, elevations at the runway centerline at points perpendicular to the proposed facility, distances from the far and near edges of taxiways and aircraft parking aprons, etc. Attach an elevation sketch if the proposed facility penetrates an airspace control surface and state the degree of the violation. Continue on a separate sheet of paper if necessary and reference by item number.)

*NOTE: This information should be the same as reflected on USAFE Form 583, Approved Waivers to Airfield and Airspace Criteria.

10.

JUSTIFICATION FOR A WAIVER (Explain in detail why the proposed facility cannot be sited to meet airfield and airspace criteria. Include a brief description of alternatives considered. Continue on a separate sheet of paper if necessary and reference by item number.)

PREVIOUS EDITION IS OBSOLETE

(OVER)

USAFE FORM 582, 20100506

11. PRECAUTIONS FOR SAFETY (Describe the safety precautions that will be taken to minimize flight safety hazards if the waiver is approved. Precautions may include special painting or lighting of obstructions, briefing programs to flying personnel and/or construction crews on safety procedures for foreign object detection and control, etc. Continue on a separate sheet of paper if necessary and reference by item number.)

12. COORDINATION AND CONCURRENCE

PRINTED NAME, GRADE AND TITLE

SIGNATURE

a. BASE CIVIL ENGINEER

b. AIRFIELD MANAGER

d. CHIEF, AIR TRAFFIC CONTROL OPERATIONS

13. OPERATIONAL RISK MANAGEMENT (ORM) CERTIFICATION

I have reviewed the requirements for this Airfield/Airspace Waiver Request, and I have determined it to be the minimum acceptable risk.

a. INSTALLATION COMMANDER (Printed Name and Grade)

b. DATE (YYYYMMDD)

c. SIGNATURE

14. ATTACHMENTS

LOCATION PLAN

SITE PLAN

ELEVATION SKETCH

OTHER (Specify)

USAFE FORM 582, 20100506 (REVERSE)

CLICK HERE TO SIGN

CLICK HERE TO SIGN

CLICK HERE TO SIGN

CLICK HERE TO SIGN

CLICK HERE TO SIGN

DATE (YYYYMMDD)

c. BASE FLIGHT SAFETY OFFICER 8.2.1.3158.1.475346.466429