Facility
Facility
VEHICLE INSPECTION RECORD -SAFETY
Name
ID No.
Bureau of Consumer and Facility Services
(See instructions on Page 2)
Address - Street or Road
City
County
ZIP Code
10 Safety Rejection—
11
1
2
3
4
5
6
7
8
9
12
Check System Rejected
Enter: serial number of
Air
Tire
Odometer
Specify
Inspection Certificate
Year
Make
Inspector’s
Bag
Pressure
Reading
What
Year________
if vehicle passes;
Not a
Not a
of
of
Certification
Repair
Susp.
(Indicate if Broken,
Wheel is
*
Vehicle
Vehicle
New York State Plate Number
Enter: “Rejected” if
Number
Reject
Reject
Order No.
Brakes
Lights
Tires
Steering
Other
(Month/Day)
Missing or Trailer)
Pulled
vehicle fails
/
*
If the vehicle does not have a plate, or displays a “Dealer” plate, enter the VIN. If an out-of state plate, enter the state and plate number.
PAGE 1 OF 2
VS-1074S (9/15)
reset/clear
Facility
Facility
VEHICLE INSPECTION RECORD -SAFETY
Name
ID No.
Bureau of Consumer and Facility Services
(See instructions on Page 2)
Address - Street or Road
City
County
ZIP Code
10 Safety Rejection—
11
1
2
3
4
5
6
7
8
9
12
Check System Rejected
Enter: serial number of
Air
Tire
Odometer
Specify
Inspection Certificate
Year
Make
Inspector’s
Bag
Pressure
Reading
What
Year________
if vehicle passes;
Not a
Not a
of
of
Certification
Repair
Susp.
(Indicate if Broken,
Wheel is
*
Vehicle
Vehicle
New York State Plate Number
Enter: “Rejected” if
Number
Reject
Reject
Order No.
Brakes
Lights
Tires
Steering
Other
(Month/Day)
Missing or Trailer)
Pulled
vehicle fails
/
*
If the vehicle does not have a plate, or displays a “Dealer” plate, enter the VIN. If an out-of state plate, enter the state and plate number.
PAGE 1 OF 2
VS-1074S (9/15)
reset/clear
I
C
V
I
R
-S
- FORM VS-1074S
NSTRUCTIONS FOR
OMPLETING
EHICLE
NSPECTION
ECORD
AFETY
The Vehicle Inspection Record (VS-1074S) is used to record inspections performed and inspection certificates issued. It is
also used to record information about vehicles that are rejected after inspection. When completed, the form must be kept
by the facility for two years after the last entry. The inspection station must enter the facility name, address and facility
number in the space provided on each form.
Use the VS-1074S to record ONLY Safety inspections and certificates. Motorcycle inspections and certificates must be
recorded on a VS-1074M; heavy vehicle and safety/diesel inspections and certificates must be recorded on a VS-1074SD.
Be sure to use the correct form for the type of inspection and certificate you are recording, and to issue and record
certificates in consecutive order. If you have a NYVIP CVIS - Do not use this form. All inspection records must
be maintained on the NYVIP CVIS.
When a vehicle is presented for inspection, you must perform a complete and thorough inspection. If the vehicle fails
because of items that need repair, adjustment or replacement, you must notify the customer of this and request
authorization before performing repairs. If the customer authorizes the repairs, complete the repairs, enter the repair order
number in column 7 and the certificate number in column 8. If the customer chooses not to have the vehicle repaired,
write “Rejected” in column 8. After repairs are completed, the inspection data should be recorded on the VS-1074S. This
includes any items that were cause for failure. These items must be checked in column 10; any notification items should
be checked in columns 11 and 12. Any items that would cause the vehicle to fail if repairs were NOT made, must be
checked on the VS-1074S.
For each inspection performed, enter the following information in the appropriate numbered column:
1. Enter the year of the inspection at the top of the column; then enter the date of the inspection (Month/Day).
2. Enter the odometer reading, as it appears on the vehicle. If the odometer is broken or missing, or if the
vehicle is a trailer, enter broken, missing or trailer.
3. Enter the model year of the vehicle, as it appears on the registration or other documents. If the year of the vehicle
is wrong, tell the customer that it should be corrected, but do not reject the vehicle for the wrong year.
4. Enter the make of the vehicle.
5. Enter the license plate number. If the vehicle does not have a plate, or displays a “Dealer” plate, enter the Vehicle
Identification Number (VIN) instead. If the vehicle has an out-of-state plate, enter the state and plate number.
6. Identify which wheel was pulled for brake inspection. If more than one wheel was pulled, indicate which ones
(RF, LF, RR, LR).
7. Enter the number of the repair order, if one was prepared. (If repairs are to be performed, an invoice must be
prepared and the customer’s authorization must be obtained.)
8. If the vehicle passes inspection, enter the number of the certificate issued. If the vehicle fails inspection, enter the word
“Rejected”.
9. From the certified inspector’s card, enter the number of the certified inspector who performed the inspection.
10. If the vehicle fails the safety inspection, check the proper box(es) for the failed item(s).
11. Check the box if there is a malfunction of the Air Bag Readiness Light (1998 and newer model year vehicles).
This is not a rejection. The motorist must be notified of the problem, in writing.
12. Check this box if tire pressure is not within specifications. Do not reject the vehicle. The motorist must be
notified of the problem.
VS-1074S (9/15)
PAGE 2 OF 2
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