PFN5900-718 X_Clean Ports Scrappage Eligibility Statement

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

Clean Ports Program
Scrappage Eligibility Statement
Burden Statement for EPA Form PFN 5900-718: 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 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.

Instructions: Please complete this form for each vehicle or piece of equipment that will be
scrapped as part of the project.
EPA Grant ID:
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: PFN 5900-718

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

By signing, I affirm that the following statements are true regarding the
vehicle/engine/equipment identified above:
1. The existing vehicle, engine, or equipment is fully operational.
2. I have owned and operated the vehicle during the two years prior to upgrade.
3. The existing vehicle, engine, or equipment has at least three years of remaining
life at the time of upgrade.
4. The existing highway vehicle has accumulated the required program mileage
minimums during the listed timeframe prior to upgrade.
5. The existing vehicle meets ALL other program requirements.

Vehicle Owner (Signature)

Date

Vehicle owner’s name: _________________________________________
Vehicle owner’s address:

____________________________________________________________

EPA Form Number: PFN 5900-718

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