Form Vs-1080r - Proof Of Hddv Repair Diesel Emissions Repair And Re-Test Certification Form
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1PROOF OF HDDV REPAIR
DIESEL EMISSIONS REPAIR AND RE-TEST CERTIFICATION FORM
INSTRUCTIONS
The inspector who tests the vehicle must complete and sign this form. The owner/operator of the vehicle must also sign
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this form.
All repairs and/or adjustments that were made to the vehicle to bring it into compliance must be accurately recorded
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below.
Copies of all repair invoices and/or part receipts, and the smokemeter printout, must be attached to this form and
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maintained for 2 years.
To reduce the amount of a fine, the vehicle must pass the emissions test, including the emissions device check.
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Within 3 days after performing the re-test, the station must mail or fax (518-402-9035) a copy of this form to: NYS
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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.
Vehicle Year ____________________________
NOTICE: All repairs listed below must be
documented on repair invoices or parts receipts (if
Vehicle Make __________________________
self-repair). Copies of the invoices or receipts
must be attached to this form.
Plate No. _______________________________
Vehicle Repairs/Adjustments Performed
Mileage ________________________________
Items Repaired/
Repair Shop
VIN __________________________________
Adjusted
Facility No.
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%
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.
-
Inspector’s Signature
Inspector’s Printed Name
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.
-
Customer’s Signature
Customer’s Printed Name
VS-1080R (9/15)
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