5900-684 TCD Scrappage Statement

OMB Control Number: 2060-New
Expiration Date: MM/DD/YYYY

EPA Office of Transportation and Air Quality
Transportation and Climate Division

Burden Statement for EPA Form 5900-684: This collection of information is approved by OMB under the
Paperwork Reduction Act, 44 U.S.C. 3501 et seq. (OMB Control No. 2060-NEW). Responses to this collection of
information are voluntary (2 CFR 200 at 2 CFR 1500). An agency may not conduct or sponsor, and a person is not
required to respond to, a collection of information unless it displays a currently valid OMB control number. The
public reporting and recordkeeping burden for this collection of information is estimated to be 2 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 to the Regulatory Support Division Director, U.S.
Environmental Protection Agency (2821T), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460. Include the
OMB control number in any correspondence. Do not send the completed form to this address.

Scrappage Statement
EPA Grant ID#: __________________

Engine make:______________________

Vehicle make: ___________________

Engine model: ____________________

Vehicle model: ___________________

Engine model year: ________________

Vehicle model year: _______________

Engine horsepower:_________________

VIN: ____________________________

Engine ID or serial number:
__________________________________

Odometer/usage meter reading:
__________________________

I certify that on _____________, the above engine and chassis were permanently
disabled. Disabling the engine consisted of drilling a three-inch hole in the engine block or
some other approved scrappage method. Disabling the chassis consisted of cutting
completely through the frame/frame-rails on each side of the vehicle/equipment at a point
located between the front and rear axles or some other approved scrappage method. The
following required digital photos of the disabled engine and chassis are attached: Side
profile of the vehicle, prior to disabling; VIN tag or equipment serial number; Engine
label (showing serial number, engine family number, and engine model year); Engine
block, prior to hole; Engine block, after hole; and Cut frame rails.

EPA Grantee/Subgrantee Authorized Representative (Print Name)

EPA Grantee/Subgrantee Authorized Representative (Signature)

Date

EPA Form 5900-684

OMB Control Number: 2060-New
Expiration Date: MM/DD/YYYY

EPA Office of Transportation and Air Quality
Transportation and Climate Division

Vehicle owner’s name and address: ______________________________________

________________________________________________________________

Vehicle Owner (Signature)

__________________

Date

Dismantler/Scrapper name and address: ________________________________________

_____________________________________________________
Dismantler/Scrapper (Signature)

_______________
Date

EPA Form 5900-684