5900-123 HD Certification Application

V1.4 -5/12

On-highway Engine and Greenhouse Gas Certification Template

Family

Test

Suppl. test

GHG

Models

Parts

Tech Desc1

Tech Desc2

Manufacturer:
Engine category:
Cert contact:

1. Model Year:

19. Plant Contact:

2. Carry over:
list

previous family:

3. Process Code:
Date EPA Fee Paid:

20. Plant Location:

4. EPA Standard

:

5. Mfr's Family Name:
6. Engine Cycle:
7. Displacement(s) (CID or Liters}
8. Engine Configuration:
Use the following format:V-8 or I-6
9. Emission Control &
Aftertreatment:

21. ABT Information:

Electronic control
Engine Modification
3WCatalyst
Smoke puff limiter
Passive DPF
Active DPF
EGR

Check all that apply

NOx adsorber
Lean NOx
SCR
DOC
None
Other

PM
NOx
NMHC

Check all that apply

The c
Non-c

NA

22. Family Emission Limits:
PM
NOx
NMHC

If Other Describe:

Units:

10. Fuel Type:
11. Fuel System Type:

23. Contact information for sending the certificate of conformity:

12. Method Of Aspiration:
FIRST NAME
TITLE
COMPANY
ADDRESS

Turbocharger Type
Aftercooling

13. Useful Life Period:

CITY
COUNTRY
E-MAIL
PHONE

14. Deterioration Factor Type
A. Gaseous Exhaust:
B. Smoke:

LAST NAME

STATE

ZIP

15. Intended Service Class
OMB No. 2060-0287
Approval Expires on
August 31, 2014
EPA Form 5900-123

If CFF, Select which category:
16. Projected Sales :

FED
CA
TOTAL

17. Estimated
Production Period:

Start
End

17a. Introduction Into Commerce Date:
18. Sales Area:

Fed

Cal

50 St

Paperwork Reduction Act Notice
The public reporting and recordkeeping burden for this collection of information
is estimated to average 13 hours per response. Send comments on the Agency's
need for this information, the accuracy of the provided burden estimates, and
any suggested methods for minimizing respondent burden, including through the
use of automated collection techniques to the Director, Collection Strategies
Division, U.S. Environmental Protection Agency (2822T), 1200 Pennsylvania Ave.,
NW, Washington, D.C. 20460. Include the OMB Number 2060-0287 in any
correspondence. Do not send the completed Form 5900-123 to this address.

Reduces effectivness of
emission control?

24. Auxiliary Emission Control Devices:

AECD

Sensed

PARAMETER

Controlled

VMT

TONS/ENGINE

Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes

25. Adjustable Parameters:
Parameter

Adjustable Range (or N/a)

Tamper Resistance Method (or N/a)

26. OBD
OBD Approval date:
OBD Approval Method:
Examples: letter from EPA , verbal from EPA, E.O. covers it

27. Maintenance Interval
Alternate Maintenance Int.?

Yes

If yes, describe
28. Is this engine family using the Delegated Assembly flexibility described in 85.1713?
If yes, attach plan in a container field on technical description page

Yes

No

Exam
Engin
Warm
Whit
Exten
Cond
Accel
Altitu
Air H
Over
PTO
Rege

29. Comments:

Engine Model Summary Template

Engine Family

1.Engine Code

2.Engine Model

3.BHP@RPM
(SAE Gross)

5.Fuel Rate:
4.Fuel Rate:
mm/stroke @ peak HP (lbs/hr) @ peak HP 6.Torque @ RPM
(for diesels only)
(SEA Gross)
(for diesel only)

7.Fuel Rate:
8.Fuel Rate:
9.Emission Control
mm/stroke@peak
(lbs/hr)@peak torqueDevice Per SAE J1930
torque

Part Number Summary Template

Engine Family

Engine
Code

Engine
Model

Injection Pump

Injector

Turbo Charge

Electronic
Control
Module

Sensor Assemblies
After Treatment Smoke Puff
Device (Specify)
Limiter
Description
Part Number