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<br />FAA REQUEST FORM FOR <br />EXPEDITED SGI WAIVER OR AUTHORIZATION FOR UAS OPERATION <br />Basic Qualifications <br /> The requesting operator must possess a Certificate of Waiver or Authorization (COA) or Part 107 Pilot License <br /> The UAS operation must support an emergency response or other effort being conducted to address exigent <br />circumstances and that will benefit the public good <br /> The requested FAA approval cannot be secured via normal processes in time to meet urgent operational needs <br /> <br />Operator Information <br /> <br />Operator Organization (e.g., agency or company) <br />South Bend Fire Department <br />Operator Address <br />1222 S. Michigan St. South Bend IN. 46601 <br />Operator Point-of Contact (including name, office + mobile phone number, and email) <br />John Nickison 574-876-9587 jnickiso@southbendin.gov <br />Pilot and Observers (including names, mobile phone numbers, and emails) <br />John Nickison (see above) Andy Petrie, Scott Mellen <br />Type of UAS and Registration Number <br />DJI Matrice 210 FA34TYLHAK <br /> <br />Documentation <br />If the requested UAS operation will be flown under a pre-existing COA, please attach it hereto and provide the COA <br />number below. <br />2019-CSA-3269-COA <br />If the requested UAS operation will be flown under Part 107, please provide the Part 107 Pilot License number below. <br />4169986 <br /> <br />Requested Flight Details <br />Enter the date(s) of the proposed UAS operation (e.g., 03/18/2018 or 03/18/2018-03/21/2018) Mandatory entry <br />04/05/2022 <br />Enter the times of the proposed UAS operation (be sure to confirm time zone; e.g., 1200L-1400L daily) Mandatory entry <br />1200-1600 <br />Enter the location of the proposed flight (reference the nearest city or town, and state; e.g., Gulfport, MS) <br />South Bend, IN. <br />Enter the distance and direction from the nearest airport, and FAA identification of the same (e.g., 6 NM W of GPT) <br />2.5 miles SE of SBN Airport <br />Identify the class(es) of airspace in which the flight will be conducted (e.g., Class G/E/D/C/B/A) <br />Class C