                                                     Control No. ______________
                                                        										         				
                                VEHICLE RELEASE
                                       
                                       
OWNER'S NAME							      DATE
	
VIN						YEAR		        MAKE & MODEL						

VEHICLE ACCEPTED					             VEHICLE REJECTED


		I, 							, owner (   ) and/or joint owner (   )


and/or principal driver (   ), acknowledge receipt of my vehicle in the same condition as when loaned to  Jacobs, a contractor to the U.S. Environmental Protection Agency, on ________________________.  I have inspected the vehicle for damage and release Jacobs  of any responsibility for damage.




			SIGNATURE							    DATE


                             Privacy Act Statement

Title 42, United States Code, Section 7451, Compliance by vehicles and engines in actual use, authorizes the collection of this information.  The primary use is to provide an instrument by which individuals may indicate interest in and eligibility for participating in EPA's Light-Duty In-Use Testing Program.  Additional disclosures of this information may be made pursuant to published routine uses, including to appropriate agencies for law enforcement purposes and to contractors working for EPA who have a need to know in the course of that work.
Providing the requested information is voluntary, but failing to do so will result in EPA's inability to approve your participation in the Light-Duty In-Use Testing Program.


This collection of information is approved by OMB under the Paperwork Reduction Act, 44 U.S.C. 3501 et seq. (OMB Control No. 2060-0086). Responses to this collection of information are voluntary (42 USC 7541.) 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 range from 1 to 60 minutes per response, with an average of 30 minutes 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. 
                                                                              	
