Document 0OmvNBMv30e82kVyJEabaXLV
Version: 2/2/2023
Nonroad Compression Ignition Engine - Field Inspection Worksheet
Instructions: This worksheet is for inspection of nonroad compression-ignition engines certified under 40 C.F.R Part 1039. Fill it in as much as possible in the field during the inspection. It can be completed electronically after the inspection.
Insp. No: 20230710-01
General Inspection Information
Carrie Griffith, Lorianny Rivera, Victor Aguilar, Nathan Dancher Inspector(s):
Insp. Date: 7/10/2023 Inspection photo 001-014
numbers:
Insp. Time Start/End: 3:30 PM EDT / 4:00 PM EDT
Photographer: Lorianny Rivera
CBP Facility Name: CBP Address 1: CBP Address 2:
CBP City/State/Zip:
Jacksonville Port of Entry 10426 Alta Dr
Jacksonville, FL 32226
Location of Inspection
Location of Goods (e.g., warehouse #1):
CBP POC: CBP Email:
Blount Island Marine Terminal
CBPO Karol Palenik KAROL.PALENIK@CBP.DHS.GOV
Entry Docs Collected from CBP
Entry/Immediate Delivery (CBP Form 3461)
Invoice
Declaration Form - Imp of Motor vehicles/Engines (CBP Form 3520-1)
Packing List
Importation of Engines, Vehicles, and Equipment subject to Air Pollution Regulations (CBP Form 3520-21)
EPA Certificate of Conformity
Other: Other: Other:
Name: Address: City/State/Zip:
POC: ID Number: Check one:
Importer Information (from Entry Documents)
Importer
Check one:
Consignee
Kobelco Construction Machinery U.S.A. Inc. 22350 Merchants Way Katy, TX 77449
holly.rink@kobelco.com
Name: Address: City/State/Zip:
POC:
ID Number:
Consignee
Buyer
Seller
Manufacturer
Check one:
Consignee
Buyer Buyer
Seller Seller
Manufacturer Manufacturer
Name: Address: City/State/Zip:
POC: ID Number:
Entry Number: Entry Date: HS Number:
Name: Address: City/State/Zip:
POC: ID Number:
Product/Entry Information (from Entry Documents)
334-70787459
Description of Product:
7/8/2023
Quantity and Units:
Total Value:
Hydraulic Excavator 14 units
$1,400,000.00
Permanent label for "DELEGATED ASSEMBLY" (1068.261)
Exemption Claims/Applicability Observations
Other:
Permanent label for test engine (1068.210)
Permanent label for "SOLEY FOR EXPORT" (1068.230)
Permanent label for manufacturer-owned and, pre-certification, test engines (citing 1068.210 or 1068.215)
Permanent label for "REPLACEMENT ENGINE" (new engine to replace in service engine) (1068.240)
Notes Excavator serial number: YN17020378
General Information (as needed)
Manual or instruction document observed? N
User Manual/Instructions
Did you photograph the document(s):?
Engine Displacement:
(specify units)
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Version: 2/2/2023
Nonroad Compression Ignition Engine - Field Inspection Worksheet
Listed Model(s): Emissions Warranty? If Yes, how long?:
Equipment Weight:
Rated Power: Rated Power RPM:
Type of Fuel:
(specify units) (e.g., @ 7,000 rpm) (e.g., 91 octane, ULSD)
Emission Control Information Label
Check Yes (Y) or No (N)
ECI Label Present:
Y
Company Information on ECI:
Can ECI label be removed without destroying:
N
Engine Family:
Did you obtain a photo of the ECI label:
Y
Emission Control Devices Listed:
Compliance Period (i.e., useful life):
Tune-up Specs Listed (Y/N): Yes, on label
Date of MFG: Displacement:
Y Refers to user manual
Type of Fuel:
Not referenced on label
Compliance statement observed? (yes/no and whether exhaust, evap, both):
Notes: Model 4TN107FTT-4WYB Engine No. 08389
MY(s) in statements:
Other Info on ECI: (as needed)
Yanmar Power Technology Co., Ltd. PYDXL04.6HDA
ECM, EM, EGR, DFI, TC, CAC, PTOX, OC, SCRC, AMOX
Mar-23 4.571 L ULSD only Yes - exhaust 2023
Type of Equipment: Model name: VIN/ESN: Build Date:
Was Part on Engine?
Check Yes (Y) or No (N)
DOC/OC:
Y
EGR:
Y
SCR/DEF:
Y
DPF/PTOX:
Y
Other (describe):
Other (describe):
Other (describe): Notes
Visual Inspection Information
Kobelco Hydraulic Excavator SK210LC-11 YN17020378
Observed Part Number
Populate part numbers if visible. Mark "not visible" if not visible and include brand name if possible. Obtain photos of each part.
Crankcase Ventilation
Crankcase vented to atmosphere?:
(4-stroke engines only, check Yes(Y) or No(N)
Evidence taken (indicate how it was marked): n/a
Field Inspection Summary
Inspector Signature: CARRIE GRIFFITH Date: 2023.09.14 20:15:48 -04'00' Digitally signed by CARRIE GRIFFITH Date:
Supervisor Signature: TODD GROENDYKE Date: 2023.09.15 10:14:33 -04'00' Digitally signed by TODD GROENDYKE
Date:
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