STATION NUMBER

DATE

Name of Station

Address

(Street)

(City)

(Zip Code)

Local Police

Police

Date loss or

County Sheriff

Report

theft occurred

State Police

No.

Reason for loss or theft

SAFETY CERTIFICATES LOST OR STOLEN

SAFETY CERTIFICATE NO.

THRU NO.

Section 448.100(f)(1) and (2) regarding loss States:

This Station Owner shall IMMEDIATELY notify the Section by telephone or telegraph of the loss or theft of any Certificate of Safety.  The owner shall, in addition, immediately notify the local police jurisdiction in which the Station is located.  The term "loss" shall include the failure to receive Certificates VIA the U.S. Mail or otherwise enroute to the Station. Each loss or theft shall be accounted for by the affidavit of the Owner stating all known details.

Signature of Owner or Authorized Agent

Note:  Immediately forward

Administrator's Copy to the

Vehicle Inspection Section

2300 S. Dirksen Parkway, Room 319

Springfield, IL 62754

Administrator's Copy

SV1-1241-1