5900-684 L_Clean Ports Scrappage Evidence Statement

OMB Control Number 2060-0754
Expiration Date: MM/DD/YYYY

Clean Ports Program
Scrappage Evidence Statement
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. 2060-0754). 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 1.5-12 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.

Instructions: Please complete this form for every vehicle or piece of equipment that has been
scrapped as part of the project. Please provide proof of scrappage of the old vehicle/engine by
attaching digital photos described below and letter signed by a representative of the scrap
yard/entity that performed the scrappage.
Note: Digital photos that require the capture of the Vehicle Identification Number (VIN) or
equipment serial number should be a readable display of the VIN or equipment serial number,
rather than a digital photo of the vehicle/engine with the VIN or equipment serial number
superimposed over the digital photo. All digital photos size be between 1KB and 5MB.
Accepted file types for the digital photos include .pdf, .png, .jpeg, and .jpg.

EPA Grant ID Number:
Vehicle/Equipment make:

Engine make:

Vehicle/Equipment model:

Engine model:

Vehicle/Equipment model year:

Engine model year:

VIN/Equipment ID or Serial Number:

Engine horsepower:

Odometer/usage meter reading:

Engine ID or Serial Number:

Vehicle registration state and number:

Equipment licensing state and number
(when applicable):

EPA Form Number 5900-684

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OMB Control Number 2060-0754
Expiration Date: MM/DD/YYYY

By signing, I affirm 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:
• Front profile of the old vehicle/engine, prior to disabling;
• Side profile of the old vehicle/engine, prior to disabling;
• VIN or engine serial number of the old vehicle/engine;
• Engine label the old vehicle/engine (showing serial number, engine family number, and engine
model year);
• Engine block the old vehicle/engine, prior to scrappage;
• Engine block the old vehicle/engine, after scrappage;
• Frame/frame-rails the old vehicle/engine, after scrappage;

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)
EPA Form Number 5900-684

Date
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