**IAP SURVEY DATA FORM**

**OBSTRUCTION DATA**

## 

**[GENERAL INFORMATION]{.underline}**

**Airport Name:** [  **       **]{.underline} **FAA Site Number:
[         ]{.underline}**

**City/State: [         ]{.underline} Airport ICAO Code:
[         ]{.underline}**

**AIP Project Number: [         ]{.underline}**

**Project Summary: [         ]{.underline}**

## Survey Information

Survey types ANP or better will support a non-precision (LNAV only)
procedure. Survey Type D or better will support an approach with
vertical guidance (APV) procedures (e.g. LNAV, VNAV or LPV). Survey type
ANAPC will support Precision CAT I approach requirements. Survey type
PIR with support Precision CAT I/II/III approach requirements.

**[CERTIFICATION]{.underline}**

**NOTE:** The registered surveyor must certify that the information
submitted herein complies with the areas, obstruction identification
surfaces (OISs), obstruction selection criteria, and accuracy
requirements of FAA No. 405 "Standards for Aeronautical Surveys and
Related Products." The Surveyor is not certifying that the submitted
information constitutes a full FAA No. 405 survey. The surveyor shall
apply their official seal to the completed form. The form shall be
signed and dated in blue ink across the applied seal.

###### I hereby certify that the information provided herein above has been compiled from accurate field surveys conducted under my direct supervision and that said information complies with the areas, obstruction identification surfaces (OISs), obstruction selection criteria and accuracy requirements of FAA Standard No. 405 "Standards for Aeronautical Surveys and Related Products" (including Change 1, effective April 15, 1998) for the survey type noted herein above.

**Surveyor's Name:
[                                               ]{.underline}**

**Surveyor's License Number: [          ]{.underline}**

**\<Affix Seal \>**

######### Runway Approach: / Survey Type: 

  ---------- -------------- --------------- -------------- --------------- --------- --------- --------- ---------- ---------- ----------
  **Object   **Latitude**   **Longitude**   **Accuracy**   **Elevation**   **HAR**   **HAT**   **HAA**   **DEND**   **DCLN**   **PNTR**
  Name**                                                                                                                       

                                                                                                                               

                                                                                                                               

                                                                                                                               

                                                                                                                               

                                                                                                                               

                                                                                                                               

                                                                                                                               

                                                                                                                               

                                                                                                                               

                                                                                                                               

                                                                                                                               

                                                                                                                               

                                                                                                                               

                                                                                                                               

                                                                                                                               

                                                                                                                               

                                                                                                                               

                                                                                                                               

                                                                                                                               

                                                                                                                               

                                                                                                                               

                                                                                                                               

                                                                                                                               

                                                                                                                               

                                                                                                                               

                                                                                                                               

                                                                                                                               

                                                                                                                               
  ---------- -------------- --------------- -------------- --------------- --------- --------- --------- ---------- ---------- ----------

#########  

######### Runway Approach: / Survey Type: 

  ---------- -------------- --------------- -------------- --------------- --------- --------- --------- ---------- ---------- ----------
  **Object   **Latitude**   **Longitude**   **Accuracy**   **Elevation**   **HAR**   **HAT**   **HAA**   **DEND**   **DCLN**   **PNTR**
  Name**                                                                                                                       

                                                                                                                               

                                                                                                                               

                                                                                                                               

                                                                                                                               

                                                                                                                               

                                                                                                                               

                                                                                                                               

                                                                                                                               

                                                                                                                               

                                                                                                                               

                                                                                                                               

                                                                                                                               

                                                                                                                               

                                                                                                                               

                                                                                                                               

                                                                                                                               

                                                                                                                               

                                                                                                                               

                                                                                                                               

                                                                                                                               

                                                                                                                               

                                                                                                                               

                                                                                                                               

                                                                                                                               

                                                                                                                               

                                                                                                                               

                                                                                                                               

                                                                                                                               
  ---------- -------------- --------------- -------------- --------------- --------- --------- --------- ---------- ---------- ----------

#########  

######### DEFINITIONS

Object - Any man made or non-man made item that extends higher than the
runway threshold elevation

Obstacle - Any object that penetrates an OIS surface

## [Field Descriptions]{.underline}

> Object = Enter Descriptive Name of Object
>
> Latitude = Geodetic Coordinate to an accuracy of two decimal places of
> a second.
>
> Longitude = Geodetic Coordinate to an accuracy of two decimal places
> of a second.
>
> Accuracy = Accuracy Code
>
> Horizontal (ft): H20 = 20'; H50 = 50'
>
> Vertical (ft): V3 = 3', V10=10'
>
> Elev. = Elevation of the top of the object
>
> HAR = Height above Runway Physical End (Report to nearest foot)
>
> HAT = Height of object above Touchdown Zone Elevation (Report to
> nearest foot)
>
> HAA = Height above Airport Elevation (Report to nearest foot)
>
> DEND = Distance Measured along the runway centerline or centerline
> extended from the runway physical end to a point abeam the object. A
> negative distance indicates that the object is on the touchdown side
> of the runway approach end. (Report to the nearest foot)
>
> DCLN = Shortest distance from the runway centerline or centerline
> extended to the object. "L" (left) or "R" (right) is relative to an
> observer facing forward in a landing aircraft. (Report to the nearest
> foot)
>
> PNTR = Penetration value of the object above the Obstacle
> Identification Surface (OIS). Report to the nearest foot
>
> **SAMPLE OBSTRUCTION SURVEY**

######### 

**Runway: [\##]{.underline} / Survey Type: [X ]{.underline}**

  ----------- -------------- --------------- -------------- --------------- --------- --------- --------- ---------- ---------- ----------
  **Object    **Latitude**   **Longitude**   **Accuracy**   **Elevation**   **HAR**   **HAT**   **HAA**   **DEND**   **DCLN**   **PNTR**
  Name**                                                                                                                        

  Ground      373927.50      -972628.52      H20/V3         1335            13        13        2         -6501      280L       3

  Obstruct.   373823.10      -972539.59      H20/V3         1328            6         6         -5        1109       129L       -11
  Light                                                                                                                         

  Light Pole  373822.01      -972527.65      H20/V3         1361            39        39        28        1684       647R       10

  Light Pole  373820.21      -972528.47      H20/V3         1362            40        40        29        1809       499R       9

                                                                                                                                

                                                                                                                                

                                                                                                                                

                                                                                                                                

                                                                                                                                

                                                                                                                                

                                                                                                                                

                                                                                                                                

                                                                                                                                

                                                                                                                                

                                                                                                                                
  ----------- -------------- --------------- -------------- --------------- --------- --------- --------- ---------- ---------- ----------

**TYPE D OBSTRUCTION EVALUATION**

**ANA OBSTRUCTION CHECKLIST**

**Revised Version: 11/03/2000**

(Based on FAA Publication 405, including the April 1998 changes)

**Obstruction Selection:** This checklist is based on a similar
checklist maintained by the National Geodetic Survey. This checklist is
to be used for the purpose of selecting objects and obstructions for an
ANAPC survey. For the purposes of this document, "obstruction" shall
mean an item that *penetrates* an OIS surface, and "object" shall mean
an item that does not *necessarily* penetrate the OIS. \"L\"(LEFT) or
\"R\" (RIGHT) is relative to an observer facing forward in a landing
aircraft.

**Accuracy Requirements**: The required accuracy of the
objects/obstructions will vary per the location of the item. Consult the
FAA project manager for the required accuracy requirements

**APPROACH AND TRANSITIONS:**

  ------------------------------------ -------------- -------------- --------------
                                       **Approach**   **Left         **Right
                                                      Transition**   Transition**

  1\) Two most penetrating             #1                            
  ***OBSTRUCTIONS*** in the first                                    
  2,566 ft.                                                          

                                       #2                            

  2\) Most penetrating ***MAN-MADE                                   
  OBSTRUCTION*** in the first 2,566                                  
  ft.                                                                

  3\) Two highest ***OBJECTS*** in     #1                            
  first 2,566 ft\                                                    
  (These must be higher than                                         
  threshold.)                                                        

                                       #2                            

  4\) Two highest ***OBSTRUCTIONS***                  #1             #1
  in first 2,566 ft.                                                 

                                                      #2             #2

  5\) The highest **OBSTRUCTION**                                    
  between 2,566 ft. and 10,000 ft.                                   

  6\) The highest ***OBSTRUCTION*** in a\.            b\.            c\.
  the first 10,000 ft.                                               

  20,000 ft.                           a\.            b\.            c\.

  30,000 ft.                           a\.            b\.            c\.

  40,000 ft.                           a\.            b\.            c\.

  7\) The highest ***OBSTRUCTION*** in a\.            b\.            c\.
  the approach or transition area.                                   
  ------------------------------------ -------------- -------------- --------------

PRIMARY

  ---------------------------------------------------------- ------------
  8\) The highest ***OBSTRUCTION*** on the approach side of  
  the threshold                                              

  9\) If approach is CAT II or CAT III, the highest          
  ***OBSTRUCTION*** each side of C/L in the primary between  
  thresholds                                                 
  ---------------------------------------------------------- ------------

MISSED APPROACH:

  ----------------------------------------------- -------------- --------------
                                                  **Left         **Right
                                                  Transition**   Transition**

  10\) The highest ***OBSTRUCTION*** each side of                
  runway C/L or C/L extended                                     

  11\) The most penetrating ***OBSTRUCTION***                    
  each side of runway C/L or C/L extended                        
  ----------------------------------------------- -------------- --------------