Form Approved OMB 2060-0095 

### United States Environmental Protection Agency Application for Final Admission of Nonconforming Imported Vehicle or Engine

1. Port of entry: 2. Entry date (mo/dy/year) : 3. Customs entry number: 4. Vehicle Identif ication Number (VIN), or engine serial number :

5. Date of original manufacture (mo/y ea r): 6. Original manufacturer: 7. Model: 8. Declaration code (letter or box number from EPA form 3520-1 or 3520-21) : 

### Names, Addresses, and Telephone Numbers of Relevant Parties
9. Importer (ICI) name and address:

Telephone number: 10. Owner name and address : 11. Address of vehicle/engine storage location (no P.O. boxes):

Telephone number:
12. Person to receive oral or written notification that EPA has not approved final admission: 13. Telephone number for item 12 : 14. Modification date:

15. EPA certificate no., model year, and expiration date of certificate applicable to this vehicle: 16. Engine family name on certificate:

17. Designate the provisions Certified vehicle imported under which the vehicle was Under 40 CFR 85.1505 imported (mark X in one box) : Modification/Test Vehicle Imported under 40 CFR 85.1509. Y ou must enter test results for each vehicle in item 18. Certified vehicles: Write the sequence number in this box of vehicles identical to the certified vehicle, begi nning with the first one imported, which is the certified prototype. Ordinarily every third sequence number must have test results in item 18 (i.e., 1 st , 4 th , 7 th , etc.). Do not count mod/test vehicles. Leave blank only if this vehicle is a mod/test vehicle. All vehicles: For fee purposes, writ e the sequence number of the vehicle covered by the currently valid certificate listed in item 15. Count both certified and mod/test vehicles. Do not leave blank.
18. Test Results (where applicable) Name, address and phone number of test laboratory:
Initial test results: (indicate applicable units and pollutants)

Test Results Deterioration factors (as applicable) Test results adjusted by the deterioration factor and rounded to two significant figures using ASTM E 29-67 rounding procedures: Emission standards Specify mileage used for full useful life ______K mi Date of test 50K full useful

life 50K full useful life 50K full useful life NMOG, NMHC, HC or NOx+HC g/mi or g/kW-hr g/mi or g/kW-hr

CO g/mi or g/kW-hr g/mi or g/kW-hr
NOx g/mi or g/kW-hr g/mi or g/kW-hr Evap. g/test g/test

HCHO or Particulates g/mi or g/kW-hr g/mi or g/kW-hr 19. Combined Fuel Economy. For passenger cars and trucks only - report the combined fuel economy value (harmonic average calculated per 40 CFR 600.513- 08(a)(2)) from the last city and highway test for each vehicle tested:EPA Form 3520-8 (Rev. 4

- 10 ) Previous versions are obsolete Pg 1 of 2 20. Place an “X” in only one box

I certify that the vehicle or engine has been modified in accordance with the provisions of a currently valid certificate of conformity. If applicable, a Federal Test Procedure was performed on the vehicle or engine in accordance with procedures in 40 CFR Part 86 o r Part 89 as applicable at a laboratory in the U.S. (40 CFR 85.1505(a)(2)(ii), 89.605(a)(2)(ii)). I certify that the vehicle or engine has been modified and the Federal Test Procedure was performed on the vehicle or engine in accordance with procedures in 40 CFR Part 86 or 89 at a laboratory in the U.S. For a v ehicle, the emission testing and develo pment of Fuel Economy data were performed after modification to Department of T ransportation safety standards. (40 CFR 85.1509(g)(2), 89.609 (b)(2)). I certify that the vehicle or engine has been modified in accordance with the provisions of a currently valid certificate of co nformity. EPA has approved the plan for me to receive information concerning OEM running changes that a ffect emissions and therefore testi ng was not required. (40 CFR 85.1505(a)(2)(i), 89.605(a)(2(i)).

21. I certify that the following statements are true: I certify that as the certificate holder I have provided or will provide to the purchaser or owner of the vehicle or engine, a s applicable: (1) written instructions for maintenance and use as required by 40 CFR 85.1510(a), 89.610(a); (2) an emissions warranty as described in 40 CFR 85.1510(b), 89.610(b), Part 85 Subpart V and Clean Air Act sections 207( a) and (b); (3) an emission label as required by 40 CFR 85.1510(c) and 89.610(c); (4) a fuel economy label as required by 40 CFR 85.1510(d) and 40 CFR Part 600 Subpart D. I certify that as the certificate holder I have complied with the applicable provisions of the Energy Act of 1978, 26 USC 4064 (gas guzzler tax) and for vehicles not owned by me I have provided the applicable tax forms to the owner; I have complied with the requirements of 40 CFR 80.24 as applicable to affix applicable unleaded fuel labels; I am responsible for the vehicle or engine compliance with Feder al emission requirements regardless of whether I own the vehicl e or engine. I certify that I have read and understand the warning below regardi ng the submission of false or fraudulent statements or conce aling a material fact, and the prohibited acts in 40 CFR 85.1513, 89.612 as applicabl e, and that the information I have provided is correct. I understand that EPA Enforcement Officers are authorized to conduct inspections or testing otherwise permitted by 40 CFR Parts 85 or 89 or other applicable provisions of the law. I will hold this vehicle or engine at least 15 working days from the date of EPA’s receipt of the final admission information u nless otherwise notified by EPA. I have paid the applicable Motor Vehicle and Engine Compliance Program fee for this v ehicle and submitted the Fee Filing Form ( EPA Form 3520-29, available at www. EPA.gov/OTAQ/fees.htm or www.Pay.gov ) with the appropriate payment. Submit the fee form according to the directions on the fee form. 22. What is the retail sales price or fair retail market value of this vehicle? 23. I request a revised cert ificate. (Attach a copy of your submitted Fee Filing Form). The number of vehicles that may be imported under a certificate is written on your certificate. If this vehicle exceeds that limit you must request a revised certificate and paythe appropriate fee prior to final importation. Warning: Any person who knowingly makes any false or fraudulent statemen t, or omits or conceals a material fact can be fined up to $25 0,000 or imprisoned for up to 5 years, or both (18 United States Code 1001). This form is required to be submi tted to EPA under 40 CFR 85.1505, 8 5.1509, 89.605, and 89.609. 24. I certify that the information on this form is true to the best of my knowledge. Signature of ICI corporate officer: Print or type name Date signed

Mailing Instructions Fax this form Attn: Final Admissions, to 734-214-4869

or mail to:

US EPA Attn: Final Admissions of ICI Vehicles 2000 Traverwood Ann Arbor, MI 48105


### Paperwork Reduction Act Notice This information is collected to ensure that motor vehicles and engines imported into the U.S. conform with applicable emission requirements. Responses to this collection are mandatory (40 CFR 85.1501 et seq., and Clean Air Ac t Sections 203 and 208). Information submitted to the Agency under a claim of confidentiality will be safeguarded according to policies set forth in Title 40, Chapter 1, Part 2, Subpart B. The public reporting and recordkeeping b urden for this collection of information is estimated to average 30 minutes per response. Send comments on th e Agency's need for this information, the accuracy of the pro vided burden estimates, and any suggested methods for minimizing respondent burden, including thr ough the use of automated collection techniques to the Directo r, Collection Strategies Division, U.S. Environmental Protection Agency (2822T), 1200 Pennsylvania Ave., NW , Washington, D.C. 20460. Do not send the completed form to this address.
For EPA use only Date final admission form received:

EPA Form 3520-8 (Rev. 4

- 1 0) Previous versions are obsolete Pg 2 of 2