5900-304 Final Vehicle Release

Control No. ______________

VEHICLE RELEASE

OWNER’S NAME DATE

VIN YEAR MAKE & MODEL

VEHICLE ACCEPTED VEHICLE REJECTED

I, , owner ( ) and/or joint owner ( )

and/or principal driver ( ), acknowledge receipt of my vehicle in the same condition as when loaned to Jacobs, a contractor to the U.S. Environmental Protection Agency, on ________________________. I have inspected the vehicle for damage and release Jacobs of any responsibility for damage.

SIGNATURE DATE

Privacy Act Statement

Title 42, United States Code, Section 7451, Compliance by vehicles and engines in actual use, authorizes the collection of this information. The primary use is to provide an instrument by which individuals may indicate interest in and eligibility for participating in EPA’s Light-Duty In-Use Testing Program. Additional disclosures of this information may be made pursuant to published routine uses, including to appropriate agencies for law enforcement purposes and to contractors working for EPA who have a need to know in the course of that work.

Providing the requested information is voluntary, but failing to do so will result in EPA’s inability to approve your participation in the Light-Duty In-Use Testing Program.

Public reporting burden for this collection of information is estimated to vary from 1 to 60 minutes per response, with an average of 30 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to Chief, Information Policy Branch, PM‑223, U.S. Environmental Protection Agency,40l M St., S.W. Washington, DC. 20460; and to the Office of Information and Regulatory Affairs, Office of Management and Budget, Washington, DC. 20503.

OMB No. 2060-0086 Expires (09/30/2014)