Official Vehicle Emissions Record Form
Agency/Department Name
Vehicle Identification Number (VIN)
License Plate Number
Vehicle Make & Model
Year
Fuel Type
Gasoline
Diesel
Electric
Hybrid
Other
Emissions Test Date
Odometer Reading
Emissions Test Results
Pollutant
Measured Value
Unit
Pass/Fail
CO (Carbon Monoxide)
g/km
HC (Hydrocarbons)
g/km
NOx (Nitrogen Oxides)
g/km
PM (Particulate Matter)
mg/km
Inspector Name
Inspector Signature
Date
Remarks / Notes