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GACA المنيه العامه للطيران المدني General Authority of Civil Aviation [Non-Text] STATEMENT OF REGULATIONS COMPLIANCE OF GACAR PART 139 <table><tr><td>No</td><td>Data Description</td><td>Information(Information to be filled with by the Applicant)</td></tr><tr><td>1.0</td><td>DETAILS OF APPLICANT/AERODROME OPERATOR</td><td></td></tr><tr><td>1.1</td><td>Full name of Applicant/Aerodrome Operator</td><td></td></tr><tr><td>1.2</td><td>Address of Applicant/Aerodrome Operator</td><td></td></tr><tr><td>1.3</td><td>Name and Location of the Aerodrome</td><td></td></tr><tr><td rowspan="2">1.4</td><td rowspan="2">Telephone/Email of Applicant/Aerodrome Operator/Accountable Executive</td><td>Tel/Mobile</td></tr><tr><td>Email</td></tr></table> <table><tr><td>No</td><td>GACAR Reference</td><td>GACAR Part 139 Description</td><td>Statement Of Compliance</td><td>Tick Mark (√) (1) Or (2)</td></tr><tr><td>1</td><td>GACAR 139 (Compliance)</td><td>GACAR 139 Sub Part A, B, C, D, E, F, G, H, I, J, K, L M and Appendix A to M.</td><td>We hereby certify that we have read all the provisions and requirements of GACAR Part 139 and its Subparts and Appendices. This aerodrome complies with all the applicable regulations of GACAR Part 139.</td><td><img></td></tr><tr><td colspan="5">Or</td></tr><tr><td>2</td><td>GACAR 139 (Non-Compliance)</td><td>GACAR 139 Sub Part A, B, C, D, E, F, G, H, I, J, K, L, M and Appendix A to M.</td><td>We hereby certify that we have read all the provisions and requirements of GACAR Part 139 and its Subparts and Appendices. There are some non-compliances of the regulations in respect of this aerodrome, and the list of all such non-compliances with mitigation measures, corrective action plan and risk assessment are submitted in the List of Non-Compliances (Form ASD-139-1632) as attached. The residual risks assessment for all non-compliances is in acceptable limits.</td><td><img></td></tr><tr><td colspan="5">We hereby certify that the forgoing information is correct in every respect and no relevant information has been withheld. The duly filled form for list of regulations non-compliances (Form: ASD-139-1632) is attached, in case (2) is applicable.</td></tr><tr><td colspan="3">Applicant/Accountable Executive Name</td><td colspan="2">Signature</td></tr><tr><td colspan="3"></td><td colspan="2"></td></tr><tr><td colspan="3">Position</td><td colspan="2">Date</td></tr><tr><td colspan="3"></td><td colspan="2"></td></tr></table> GACA-AVSES-AGA-F019 Rev: 2, Date: 09 Apr 25 Page 1 of 1