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MFG P/N: 622-5027-101 SERIAL No.: tG5OG

DESCRIPTION; QTY: I 15N:

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CSN:
BATCH No,; LOAN INFO
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CSO:
;TOB[5 INSPECTOR NAME:

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NSP. AUTH.
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NSP. DATE:

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NSTALLATION DATA:
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CERTIFICATE OF RELEASE TO SERVICE IIICX
AS REAUIRED I OH[.] INStrI REPAIR r'I MODr']
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REGULATIONS 18 AND lN RESPECT To WHAT woRK THE AtRcRArr / AtRCRAFT coMpoNENT ts coNstDERED READv FoR RELEASE To
SERVICE

SIGNATURE: DATE: STAMP

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REASON OF REMOVAL:
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FBA/MNT/SC/007 tssue: 19 Oct 2019 Rev.0
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