A-1 Limo & Bus Repair, New York | Bus Inspection MC19 1b

NYS DOT Bus Inspection MC19 1b

Please Fill in the Following Information

* Operation Information

Oper Id:	*	Type Oper:	*
Number of Vehicles:	*
Company :	*
Address:	*
City:	*
State:	*
Zip Code:
Phone#:	*	Ext:
Fax :

Inspection Information

Location :	*
Address:	*
City:	*	State:	*	Zip Code:
Phone#:	*	Ext:		Fax:
Manager:	*

Adequate Facility

Pit

Lift

Phone

Electric Desk

Other

Does the manager have a copy of the current out of service criteria?

Yes No

Yes, please send NYSDOT information via e-mail to the following address:

Name:	*	E-Mail Address:	*
Name:	*	E-Mail Address:	*

INSPECTION NOTIFICATION INFORMATION
Motor Vehicles shall be presented for inspection at the time and place designated by a duly authorized representative Department. The following individual(s) is/are responsible to insure that any required records and vehicle(s) are available Inspection:

Name:	*	E-Mail Address:	*
Name:	*	E-Mail Address:	*

ACCIDENT/INCIDENT NOTIFICATION INFORMATION
The following individuals are familiar with the requirements as contained in NYCRR Title 17 Part 722 and are primarily responsible to report accidents/incidents to the NYDOT.

Name:	*	Tel. No:
Name:	*	Tel. No

Prepared by:	*	Date:
	Motor Vehicle Inspector

DULY AUTHORIZED COMPANY REPRESENTATIVE CERTIFICATION:
I am a duly authorized representative of the organization as indicated above. I reviewed the information on this form and to the best of my knowledge find it to be true and accurate.

Name:

Title.:

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