5900-688 CHDV Supplemental Application Template

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 5900-688: 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.

Diesel Emissions Reduction Act (DERA)
Scrappage Statement
EPA Grant ID#:
Vehicle make:

Engine make:

Vehicle model:

Engine model:

Vehicle model year:

Engine model year:

VIN:

Engine horsepower:

Odometer/usage meter reading:

Engine ID or serial number:

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

Vehicle owner’s name and address:

______________________________________________________
Vehicle Owner (Signature)

______________
Date

Dismantler/Scrapper name and address:

______________________________________________________
Dismantler/Scrapper (Signature)

______________
Date
EPA Form Number: 5900-688