5900-688 P_DERA Scrappage Statement

OMB Control No. 2060-0754
Expiration Date 4/30/2027

Diesel Emissions Reduction Act (DERA)
Scrappage Statement
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. 2060-0754). 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 each vehicle or piece of equipment scrapped as part of this
project.

EPA Grant Identification:
Vehicle/Equipment make:

Engine make:

Vehicle/Equipment model:

Engine model:

Vehicle/Equipment model year:

Engine model year:

Vehicle Identification Number/Equipment
Identification or Serial Number:

Engine horsepower:

Odometer/usage meter reading:

Engine Identification or Serial Number:

Vehicle registration state and number:

Equipment licensing state and number
(when applicable):

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:
EPA Form Number 5900-688

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OMB Control No. 2060-0754
Expiration Date 4/30/2027

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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;

Vehicle/Engine Scrappage Evidence Instructions:
Please provide proof of scrappage of the old vehicle/engine by attaching digital photos and letter. Attach
photos of the destroyed engine and frame/frame-rails that clearly displays the last 4 digits of the vehicle
VIN or engine serial number as proof of old vehicle/engine scrappage, if applicable. Attach a letter signed
by a representative of the scrap yard/entity that performed the scrappage.

New Vehicle/Engine Photo Information:
Please provide the following for each new vehicle/engine purchased;
• Front profile of the new vehicle/engine;
• Side profile of the new vehicle/engine;
• VIN or engine serial number of the new vehicle/engine;
New Infrastructure Photo Information, if applicable:
Please provide the following for infrastructure (chargers, shore power, etc.) purchased with DERA
program funds, if applicable:
• Clear photo of each infrastructure’s data plate;
• Clear photo of each installed infrastructure;
Note: Digital photos that require the capture of the 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 Grantee/Subgrantee Authorized Representative (Print Name)

_________________________________________________________
EPA Grantee/Subgrantee Authorized Representative (Signature)

EPA Form Number 5900-688

______________
Date

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OMB Control No. 2060-0754
Expiration Date 4/30/2027

Vehicle owner’s name and address:

_________________________________________________________
Vehicle Owner (Signature)

______________
Date

Dismantler/Scrapper name and address:

_________________________________________________________
Dismantler/Scrapper (Signature)

EPA Form Number 5900-688

______________
Date

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