Form Vs-1074s - Vehicle Inspection Record-Safety
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1
2Facility
Facility
VEHICLE INSPECTION RECORD -SAFETY
Name
ID No.
Bureau of Consumer and Facility Services
(See instructions on Page 2)
Address - Street or Road
City
County
ZIP Code
10 Safety Rejection—
11
1
2
3
4
5
6
7
8
9
12
Check System Rejected
Enter: serial number of
Air
Tire
Odometer
Specify
Inspection Certificate
Year
Make
Inspector’s
Bag
Pressure
Reading
What
Year________
if vehicle passes;
Not a
Not a
of
of
Certification
Repair
Susp.
(Indicate if Broken,
Wheel is
*
Vehicle
Vehicle
New York State Plate Number
Enter: “Rejected” if
Number
Reject
Reject
Order No.
Brakes
Lights
Tires
Steering
Other
(Month/Day)
Missing or Trailer)
Pulled
vehicle fails
/
*
If the vehicle does not have a plate, or displays a “Dealer” plate, enter the VIN. If an out-of state plate, enter the state and plate number.
PAGE 1 OF 2
VS-1074S (9/15)
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Parent category: Legal