New York State Department of Motor Vehicles DIESEL EMISSION INSPECTION CERTIFICATION AND WAIVER FORM www.nysdmv.com INSTRUCTIONS: This form must be completed by both the customer and the inspection station granting the waiver. The station granting the waiver must keep copies of invoices and receipts for all diagnostic and repair work done so the vehicle would qualify 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 DMV or DEC personnel. Within 3 days after granting the waiver and issuing an inspection certificate for this vehicle, the station must mail copies of: (1) invoices and receipts for all diagnostic and repair work completed so the vehicle would qualify 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, 625 Broadway, Albany NY 12233-3255. FOR A STATION TO GRANT A WAIVER, ALL THE FOLLOWING CONDITIONS MUST BE MET: 1. The vehicle must pass the safety inspection and the emission 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 emission-related repairs (excluding replacing missing emission control devices) must meet or exceed the waiver limit checked below. 3. The repairs must be recorded accurately on this form. VEHICLE AND FACILITY DESCRIPTION NOTICE: All repairs listed below must be documented on repair receipts and invoices. The documents must be attached to this form and kept by the inspection station for review by the state. Vehicle Year__________________________________ VEHICLE REPAIRS PERFORMED Vehicle Make ________________________________ Items Repaired/Adjusted Repair Shop Facility # Cost ________________________________ ______________ __________ ________________________________ ______________ __________ Mileage ____________________________________ ________________________________ ______________ __________ Vehicle ID No. (VIN) ____________________________________ ________________________________ ______________ __________ ________________________________ ______________ __________ Certificate Number ____________________________ ________________________________ ______________ __________ ________________________________ ______________ __________ Plate Number ________________________________ Inspection Station No. __________________________ Total Cost $0.00 ______________ Inspector No. ________________________________ Check Waiver Date ________________________________ (Waiver expires one year from this date) Proper Maximum Gross Weight (MGW) Minimum Repair Cost For Hardship Waiver 8,501 to 18,000 $1,000 Waiver 18,001 to 26,000 $2,000 Cost Over 26,000 $4,000 Weight & Final Emission Test Readings: ___________ Opacity (%) 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 described vehicle.  _____________________________________________________ Inspector’s Signature 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.  _____________________________________________________ VS-1079DE (11/07) Customer’s Signature American LegalNet, Inc. www.FormsWorkFlow.com