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VEHICLE OWNER INFORMATION
Full Name:
Address:
City:
State:	Zip:
Email:		Phone:

VEHICLE INFORMATION

Model Year:

Make:

Model:

License: State: VIN:

Engine Size: Type: Transmission:

GVWR: Test Weight: Cylinders:

Odometer: Certification: VLT Record No.:

Fuel Type: Exhaust: Inspection Reason:

OVERALL TEST RESULTS

Visual Inspection: Functional Check: Emissions Test:

EMISSION CONTROL SYSTEMS VISUAL/FUNCTIONAL INSPECTION

There are components on your VIR report which do not appear below. Fill-in only the results of the components listed.

PCV

Fuel Cap Functional

Air Injection

Catalytic Converter Spark Controls Ignition Timing

EGR
(Visual) Fuel Evap Controls Functional MIL / Check Engine Light

EGR
(Functional) Thermostatic Air Cleaner Oxygen Sensor

ASM EMISSIONS TEST RESULTS (1999 & older vehicles only)

%CO₂ %O₂ HC (PPM)

Test Speed RPM MEAS MEAS MAX AVE MEAS

15 MPH

25 MPH

CO (%) NO (PPM)

Test Speed MAX AVE MEAS MAX AVE MEAS RESULTS

15 MPH

25 MPH

MAX=Maximum Allowable Emissions AVE=Average Emissions For Passing Vehicles
MEAS=Amount Measured GP=Gross Polluter Amount
If your vehicle is a Gross Polluter, fill in the emission numbers in the order they appear on your VIR. (You may replace the "Ave" spaces with your VIR's "GP" values).

SMOG STATION INFORMATION

Shop Name:

Address:

Zipcode:

ADDITIONAL VEHICLE INFORMATION
Please use the space below to provide additional information regarding your vehicle, such as recent repairs, trouble codes, drivability problems and/or engine symptoms (ie. lack of power, smoking...).

VERIFICATION: Please verify your smog check
was performed at a SmogTips certified smog station

Date/Time of your smog check?

How much did your smog check cost?

Did you receive satisfactory service?

What is your invoice or work order number?

VEHICLE INFORMATION
Model Year:	Make:	Model:
License:	State:	VIN:
Engine Size:	Type:	Transmission:
GVWR:	Test Weight:	Cylinders:
Odometer:	Certification:	VLT Record No.:
Fuel Type:	Exhaust:	Inspection Reason:

EMISSION CONTROL SYSTEMS VISUAL/FUNCTIONAL INSPECTION There are components on your VIR report which do not appear below. Fill-in only the results of the components listed.
	PCV	Fuel Cap Functional	Air Injection
	Catalytic Converter	Spark Controls	Ignition Timing
	EGR (Visual)	Fuel Evap Controls Functional	MIL / Check Engine Light
	EGR (Functional)	Thermostatic Air Cleaner	Oxygen Sensor

VERIFICATION: Please verify your smog check was performed at a SmogTips certified smog station
Date/Time of your smog check?
How much did your smog check cost?
Did you receive satisfactory service?
What is your invoice or work order number?