DIESEL EMISSIONS INSPECTION CERTIFICATION AND WAIVER FORM
dmv.ny.gov
INSTRUCTIONS:
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This form must be completed by both the customer and the inspection station granting the waiver.
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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.
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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.
NOTICE: All repairs listed below must be documented on repair receipts and
VEHICLE AND FACILITY
invoices. These documents must be attached to this form and kept by the
DESCRIPTION
inspection station for review by the state.
Vehicle Year__________________________________
VEHICLE REPAIRS PERFORMED
Repair Shop
Items Repaired/Adjusted
Cost
Facility No.
Vehicle Make ________________________________
________________________________
______________
__________
Plate No. ____________________________________
________________________________
______________
__________
Mileage ____________________________________
________________________________
______________
__________
________________________________
______________
__________
Vehicle ID
No. (VIN) ____________________________________
________________________________
______________
__________
________________________________
______________
__________
Certificate No. ________________________________
________________________________
______________
__________
Inspection Station No. __________________________
$0.00
Total Cost
______________
Inspector No. ________________________________
Maximum Gross Weight
Minimum Repair Cost For
Check
(MGW)
Hardship Waiver
Waiver Date
________________________________
Proper
(Waiver expires one year from this date)
8,501 to 18,000
$1,000
Weight &
Reason for Waiver: ____________________________
$2,000
18,001 to 26,000
Waiver
Final Emissions Test Readings: ___________ Opacity (%)
Cost
$4,000
Over 26,000
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.
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______________________________________________
_________________________________________________
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.
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______________________________________________
_________________________________________________
Customer’s Signature
Customer’s Printed Name
VS-1079DE (9/15)
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