Other Form itia2111 • • larghr, Mande Wage and Tax Statement 2004 :„ndY 12e C 120 lad 1137.25 Department of the Treacyry - Internal Rove nuc Servl For Privacy pot and Paparwork Reduction Act Nett and instructions, coo Form1N-38 EFTA00233131 a Control number b • sensor e EMplOVIIIS name,

range lidi per 14 CFR Pan 43 APP. B D Signaturallate ol AulhOrneel Indiviebal Anton J. Koptivnik 12/29/2013 f .....,fle f 1. Ap val til to Servl Insinuant lo the mitimmy given persons emne) belma, am un I iderilMed in den 5 was inspecied in Ne manne veoxibtrl by gle Adilinelreke Cd the Feder

information to the best of my knowledge. Date 'A4/ . Signature of Authorized indivi lobo K. Urso. Inspector. 4 (Ler— 7. Approval for Return to Servl Pursuant Administrator BY to the authority given persons of the Federal Aviation specified below, the unit derained in item 4 was inspected in

ect to the best of my knowledge. Date -71WO / Signature of Authorized Individ I John K. Urso. Inspector. C.- ,a441 --- 7. Approval for Return to Servl Pursuant Administrator BY to the authority given of the Federal Aviation persons specified below, the unit Administration and is identified i

rrect to the best of my knowledge. Date 7/2/01 . Signature of Authorized lndi idual John K. Urso. Inspector. L,,, /C. 7. Approval for Return to Servl Pursuant Administrator BY to the authority given persons specified below, the unit of the Federal Aviation Administration and is identified in

correct to the best of my knowledge. Date . . 2/19/03 Signature of Authorized Individual John K. Urso, Inspector. /6 7. Approval for Return to Servl Pursuant Administi.ator BY to the authority given of the Federal Aviation persons specified below, the unit identified in item 4 w s inspected