Form VS-1079DE - Diesel Emissions Inspection Certification - New York - Edit, Fill, Sign Online

VEHICLE REPAIRS PERFORMED

Repair Shop

Items Repaired/Adjusted Cost Facility No.

________________________________ ______________ __________

Total Cost ______________

DIESEL EMISSIONS INSPECTION CERTIFICATION AND WAIVER FORM

www.dmv.ny.gov

INSTRUCTIONS:

s This form must be completed by both the customer and the inspection station granting the waiver.

s The station granting the waiver must keep copies of invoices and receipts for all diagnostic and repair work done to qualify the vehicle

for an emissions waiver, regardless of who performed the work. The station must also keep a copy of the previous smokemeter printout(s)

showing the failing opacity. All documents must be kept for 2 years for review by Department of Motor Vehicles (DMV) or Department

of Environmental Conservation (DEC) personnel.

s Within 3 days after granting the waiver and issuing an inspection certificate for this vehicle, the station must mail or FAX (518-402-9035)

copies of: (1) invoices and receipts for all diagnostic and repair work completed to qualify the vehicle for an emissions waiver, (2) a copy

of the previous smokemeter printout(s) and the final smokemeter printout showing the failing opacity, and (3) a completed copy of this

form to: NYSDEC, Division of Air Resources, Bureau of Mobile Sources and Technology Development, Heavy Duty Vehicle Program,

625 Broadway, Albany NY 12233-3255.

FOR A STATION TO GRANT A WAIVER, ALL OF THE FOLLOWING CONDITIONS MUST BE MET:

1. The vehicle must pass the safety inspection and the emissions control device check. This inspection must also be at least the second

emissions failure for this vehicle within 30 days.

2. The cost of all emissions-related repairs (excluding replacing missing emissions control devices) must meet or exceed the waiver limit

checked below.

3. The repairs must be recorded accurately on this form.

If you have any questions about this form, call NYSDEC at (518) 402-8292.

VEHICLE AND FACILITY

DESCRIPTION

Vehicle Year__________________________________

Vehicle Make ________________________________

Plate No. ____________________________________

Mileage ____________________________________

Vehicle ID

No. (VIN) ____________________________________

Certificate No. ________________________________

Inspection Station No. __________________________

Inspector No. ________________________________

Waiver Date ________________________________

(Waiver expires one year from this date)

Reason for Waiver: ____________________________

Final Emissions Test Readings: ___________ Opacity (%)

NOTICE: All repairs listed below must be documented on repair receipts and

invoices. These documents must be attached to this form and kept by the

inspection station for review by the state.

INSPECTOR’S CERTIFICATION

I certify that copies of invoices and/or receipts supporting the repair items listed above are attached to this document. To the best of my

knowledge, the work described above has been performed on the vehicle described.

______________________________________________ _________________________________________________

Inspector’s Signature Inspector’s Printed Name

-

CUSTOMER’S CERTIFICATION

I certify that, to the best of my knowledge, the diagnostic and repair work described on this form has been performed. Copies of invoices

and/or receipts are attached.

______________________________________________ _________________________________________________

Customer’s Signature Customer’s Printed Name

-

VS-1079DE (9/15)

Maximum Gross Weight

(MGW)

8,501 to 18,000 $1,000

$2,000

$4,000

18,001 to 26,000

Over 26,000

Check

Proper

Weight &

Waiver

Cost

Minimum Repair Cost For

Hardship Waiver

Fillable Printable Form VS-1079DE - Diesel Emissions Inspection Certification - New York

Fillable Printable Form VS-1079DE - Diesel Emissions Inspection Certification - New York

Form VS-1079DE - Diesel Emissions Inspection Certification - New York