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Fillable Printable Form VS-1080R - Proof of HDDV Repair - New York

Fillable Printable Form VS-1080R - Proof of HDDV Repair - New York

Form VS-1080R - Proof of HDDV Repair - New York

Form VS-1080R - Proof of HDDV Repair - New York

PROOF OF HDDV REPAIR
DIESEL EMISSIONS REPAIR AND RE-TEST CERTIFICATION FORM
INSTRUCTIONS
u The inspector who tests the vehicle must complete and sign this form. The owner/operator of the vehicle must also sign
this form.
u
All repairs and/or adjustments that were made to the vehicle to bring it into compliance must be accurately recorded
below.
u Copies of all repair invoices and/or part receipts, and the smokemeter printout, must be attached to this form and
maintained for 2 years.
u To reduce the amount of a fine, the vehicle must pass the emissions test, including the emissions device check.
u Within 3 days after performing the re-test, the station must mail or fax (518-402-9035) a copy of this form to: NYS
Department of Environmental Conservation, Division of Air Resources, Bureau of Mobile Sources and Technology
Development, 625 Broadway, Albany, NY 12233-3255. If you have any questions, call NYSDEC at 518-402-8292.
INSPECTOR’S CERTIFICATION
I certify that copies of invoices and/or receipts supporting the repair items listed above are attached to this document, and that,
to the best of my knowledge, the work described above has been performed on the vehicle described. I have tested the vehicle
described above and certify that it now passes the Diesel Emissions test. The opacity reading (%) is stated above.
CUSTOMER’S CERTIFICATION
I, ___________________________________________ , am the owner/operator of the vehicle identified above. I certify that, to
the best of my knowledge, the repair work described above has been performed.
Vehicle Year ____________________________
Vehicle Make __________________________
Plate No. _______________________________
Mileage ________________________________
VIN __________________________________
Ticket No. ______________________________
Inspection Station No. ____________________
Certified Inspector No. ____________________
Test Date ______________________________
Engine Model Year ______________________
Opacity Test Reading____________________%
Vehicle Cut Points
Engine Model Year
Maximum Opacity %
1973 and older 70%
1974 - 1990 55%
1991 and newer 40%
NOTICE: All repairs listed below must be
documented on repair invoices or parts receipts (if
self-repair). Copies of the invoices or receipts
must be attached to this form.
Vehicle Repairs/Adjustments Performed
____________________ ________________
____________________ ________________
____________________ ________________
____________________ ________________
____________________ ________________
____________________ ________________
____________________ ________________
Inspector’s Signature
Customer’s Signature
VS-1080R (9/15)
-
-
Items Repaired/
Adjusted
Repair Shop
Facility No.
Inspector’s Printed Name
Customer’s Printed Name
reset/clear
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