PFN5900-719 Y_Clean Ports Technology Deployment Evidence Statement

OMB Control No. 2060-0754
Expiration Date MM/DD/YYYY

Clean Ports Program
Technology Deployment Evidence Statement
Burden Statement for EPA Form PFN 5900-719: This collection of information is approved by OMB under the

Paperwork Reduction Act, 44 U.S.C. 3501 et seq. (OMB Control No. XXXX-XXX). 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 Director, Information Engagement Division, 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.

Deployment Evidence Instructions: Please complete this form for each funded zero-emission vehicle,
piece of equipment, powertrain, and/or charging/fueling infrastructure. Provide proof of deployment by
attaching digital photos consistent with the below instructions.

EPA Grant Identification Number:
Vehicle/equipment make:
Vehicle/equipment model:
Vehicle/equipment model year:
Vehicle Identification Number
(VIN)/ Equipment ID or Serial
Number:
Odometer/hour/usage meter reading:
Powertrain make:
Powertrain model:
Powertrain model year:
Powertrain horsepower:
Powertrain ID or serial number:

EPA Form Number PFN 5900-719

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OMB Control No. 2060-0754
Expiration Date MM/DD/YYYY

Type of Infrastructure:
Infrastructure Manufacturer:
Infrastructure Model:
Infrastructure Serial Number(s):

By signing, I affirm that on______________, the above vehicle, equipment, powertrain, and/or
charging/fueling/other infrastructure was deployed and/or installed, and fully operational. The
following required digital photos are attached:

New Vehicle/Equipment/Powertrain Photo Information
Please provide the following:
• Front profile view
• Side profile view
• View of VIN or serial number
Note: Digital photos of the VIN or serial number should show a readable display of the VIN or
serial number, rather than a digital photo of the vehicle/equipment/powertrain with the VIN or
serial number superimposed over the digital photo. All digital photos must be between 1KB and
5MB in size. Accepted file types for the digital photos include .pdf, .png, .jpeg, and .jpg.
New Charging/Fueling/or Other Infrastructure Photo Information
Please provide the following:
• View of charging/fueling infrastructure
• View of data plate(s)

EPA Form Number PFN 5900-719

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OMB Control No. 2060-0754
Expiration Date MM/DD/YYYY

______________________________________________________
EPA Grantee/Subgrantee Authorized Representative (Print Name)

______________________________________________________
EPA Grantee/Subgrantee Authorized Representative (Signature)

________________
Date

______________________________________________________
Vehicle/equipment/powertrain/infrastructure Owner (Print Name)
______________________________________________________
Vehicle/equipment/powertrain/infrastructure Owner (Signature)

________________
Date

Vehicle/equipment/powertrain/infrastructure Owner physical address:

______________________________________________________

EPA Form Number PFN 5900-719

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