PUBLIC SERVICE VEHICLE STATE OF CONNECTICUT …

1 DEALER/REPAIRER LICENSE INFORMATION (SECTION B) - MUST BE COMPLETEDSTATE OF CONNECTICUTDEPARTMENT OF MOTOR VEHICLESCOMMERCIAL VEHICLE safety DIVISIONPUBLIC SERVICE VEHICLELICENSED DEALER/REPAIRER INSPECTOR REPORTR-361 REV. 6-2007 Instructions for Owner/Carrier: This report is to be used by a CONNECTICUT licensed dealer/repairer. When inspecting any SERVICE bus or taxicab motorvehicle for registration purposes (Renewals Only).1. The owner/carrier of the VEHICLE must complete Section A in its The owner/carrier must submit a photocopy of this PASSED report along with the renewal INFORMATION (SECTION A) - MUST BE COMPLETED BY VEHICLE OWNEROWNER/CARRIER NAME (Not Lessee)PHONE NUMBERADDRESSTOWN/CITYSTATEZIP CODEMARKER PLATE NUMBERYEARMAKEMODELBODY STYLEVEHICLE TYPETAXISERVICE BUSVINMANUFACTURER'SSEATING CAPACITYGVWRNAME OF REPAIRER/GARAGEPHONE NUMBERADDRESSTOWN/CITYSTATEZIP CODEPRINCIPALDEALER/REPAIRER LICENSE NUMBERDEALER/REPAIRER INSPECTION SECTION (SECTION C)INSPECTION ITEMPASSFAILCOMMENTS (Describe Violation)REINSPECTIONPASSSERVICE BRAKESPARKING BRAKETIRES/WHEELSSTEERING SYSTEMSUSPENSIONFRAME/CHASSISEXHAUSTFUEL SYSTEMHEADLIGHTSSTOP/TURN LIGHTSMISC.

2 LIGHTSWIPERS/WASHERWINDSHIELD GLAZEFAILHORNEMERGENCYEQUIPMENTMIRRORSSE ATS/SEAT BELTSHEATER/DEFROSTEROTHERDEALER/REPAIRE R INSPECTION CERTIFICATION (SECTION D) - MUST BE COMPLETEDIf the repairs are not completed by the inspecting facility, the dealer/repairer must allow for one free reinspection. All of the defects noted on the report must be repaired before the VEHICLE can be to the Regulations of CONNECTICUT STATE Agencies Section 14-63-40, each dealer/repairer must maintain a copy of the inspection report and the repair documentation on file at its licensed location for aperiod of two (2) years after the repair of the VEHICLE . Customer must submit a photocopy of this report along with the renewal INSPECTION RESULTSPASSFAILAUTHORIZED SIGNATURE OF DEALER/REPAIRERDATE OF INSPECTIONREINSPECTION RESULTSPASSFAILAUTHORIZED SIGNATURE OF DEALER/REPAIRERDATE OF REINSPECTIONThe information provided to the Commissioner of Motor Vehicles herein is subscribed by me, the undersigned, under penalty of false statement inaccordance with the provisions of Section 14-110 and 53a-157b of the CONNECTICUT General Statutes.

3 I understand that if I make a statement which I donot believe to be true, with the intent to mislead the Commissioner, I will be subject to prosecution under the above cited Signature of Dealer/RepairerDateA COPY OF THIS DOCUMENT MUST BE MAINTAINED IN THE VEHICLE WITH THE REGISTRATIONINSPECTIONXI nstructions for CONNECTICUT Licensed Dealer/Repairer: The CONNECTICUT licensed dealer/repairer must complete Section B, C, and the certification inSection D in its ENTIRETY. By completing Section (D), the licensed dealer/repairer is certifying that the VEHICLE meets inspection standards as outlined bythe Department of Motor Vehicles. If repairs are not completed by the inspecting facility, the dealer or repairer must allow for one free inspection. All of thedefects on the report must be repaired before the VEHICLE can be.

4 Pursuant to the Regulations of CONNECTICUT STATE Agencies Section 14-63-40.

5 Each dealer/repairer must maintain a copy of the inspection report andthe repair documentation on file at licensed location for a period of two (2) years after the inspection/repair of the ACTUALMILEAGE BELOW(ODOMETER READING)