Fillable Printable 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

uThe inspector who tests the vehicle must complete and sign this form. The owner/operator of the vehicle must also sign

this form.

All repairs and/or adjustments that were made to the vehicle to bring it into compliance must be accurately recorded

below.

uCopies of all repair invoices and/or part receipts, and the smokemeter printout, must be attached to this form and

maintained for 2 years.

uTo reduce the amount of a fine, the vehicle must pass the emissions test, including the emissions device check.

uWithin 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

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