SECTION A - OWNER INFORMATION

Ownership Type: (Select only one and complete the appropriate section below.)

Franchise

Sole Proprietor

Corporation

Partnership

Owner/CEO/Owner's Authorized Official First Name

Owner/CEO/Owner's Authorized Official Last Name

Home Address Line 1

Home Address Line 2

City

State

Zip Code

Zip Code Plus

County

E-mail Address

By checking this box I give GCAF permission to forward my email address to the Industry Advisory Board (IAB) so that I may receive current IAB updates and membership information.

Owner Contact Person

Owner Phone Number (xxx) xxx-xxxx

Have you ever been certified as a Georgia Emissions Inspector or held a Certificate of Authorization for an inspection station?

Yes

If you answered "Yes," please provide the following

Station ID#

Inspector ID#

Former Station Name (If applicable)

Have you ever had your inspection or station certification denied, suspended, revoked or voluntarily surrendered?

Yes

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Name of Corporation

Contact Person

Office Address

Suite/Apt#

City

State

Zip Code

Phone Number

SECTION B - STATION INFORMATION

Business Federal Tax ID Number

Partner 1

Name of Partner 1

Office Address

Suite/Apt#

City

State

Zip Code

Phone Number

Partner 2

Name of Partner 2

Office Address

Suite/Apt#

City

State

Zip Code

Phone Number

Partner 3

Name of Partner 3

Office Address

Suite/Apt#

City

State

Zip Code

Phone Number

Partner 4

Name of Partner 4

Office Address

Suite/Apt#

City

State

Zip Code

Phone Number

Station Name

Station Address Line 1

Station Address Line 2

City

State

Zip Code

Zip Code Plus

County

Station Phone (xxx) xxx-xxxx

Station Email Address

By checking this box I give GCAF permission to forward my email address to the Industry Advisory Board (IAB) so that I may receive current IAB updates and membership information.

**A permanent voice communication line or cell phone line is required for onsite communication with the station by the EPD, GCAF, and station customers. If changed, this number must be immediately updated with GCAF.

Check this box if your station address is the same as your mailing address.

Station Mailing Address (if different from above)

Station Mailing Address Line 2

City

State

Zip Code

Zip Code Plus

County

(A) Station Manager's First Name

Station Manager's Last Name

Station Manager's Direct Phone Number

Station Manager's Email Address

By checking this box I give GCAF permission to forward my email address to the Industry Advisory Board (IAB) so that I may receive current IAB updates and membership information.

(B) Station Manager's First Name

Station Manager's Last Name

Station Manager's Direct Phone Number

Station Manager's Email Address

By checking this box I give GCAF permission to forward my email address to the Industry Advisory Board (IAB) so that I may receive current IAB updates and membership information.

Station Manager's Last Name

Station Manager's Direct Phone Number

Station Manager's Email Address

By checking this box I give GCAF permission to forward my email address to the Industry Advisory Board (IAB) so that I may receive current IAB updates and membership information.

(1) What is the name of the manufacturer of the GAS unit?

WORLD WIDE

SPX/BOSCH

ESP/OPUS

GAS Model Number

GAS Serial Number

Static IP Address

(2) What is the name of the manufacturer of the GAS unit?

WORLD WIDE

SPX/BOSCH

ESP/OPUS

GAS Model Number

GAS Serial Number

Static IP Address

(3) What is the name of the manufacturer of the GAS unit? This is not your access code

WORLD WIDE

SPX/BOSCH

ESP/OPUS

GAS Model Number

GAS Serial Number

Static IP Address

SECTION C - TYPE OF CERTIFICATION DESIRED

Are inspections performed by Appointment Only?

Yes

What are the total hours your station will be open per week?

Check all boxes that describe the station.

SECTION D - INSURANCE INFORMATION

Do you have the required insurance?

Yes

Policy Number

Insurer(s)

Insurance Agency (If purchased from someone other than the insurer)

Contact Name

Phone Number (xxx) xxx-xxxx

Effective Date (mm.dd.yyyy)

Expiry Date (mm.dd.yyyy)

Liability Coverage Amount $ (In whole dollars with no commas)

Is Georgia's Clean Air Force a certificate holder?

Yes

SECTION E - STATION INSPECTOR LIST

Inspector Name

Certification Number

Not Yet Certified

SECTION F – SITE EVALUATION QUESTIONAIRE

Please check the appropriate boxes that apply to your proposed station.

1. Does the facility have adequate room for four (4) vehicles per lane to wait in queue for an emissions inspection without impeding traffic on a public road?

Yes

2. Does the facility have a proposed location to install the required station sign so it will be in view of the motoring public and meet local zoning requirements?

Yes

Describe the location of the station sign

3. Does the facility have adequate length, width and height to accommodate all normal sized vehicles presented for inspection?

Yes

4. The GAS must be maintained between 41 and 100 degrees Fahrenheit at all times when inspecting vehicles. Does the facility have temperature controls to keep the GAS unit within this range?

Yes

Describe temperature controls in the station

5. Will the inspection facility have a public viewing area to allow motorists to clearly observe the entire emission inspection of their vehicle?

Yes

6. Will the facility have an area visible to the public to display the station license?

Yes

Describe the area

7. Will the facility have an area accessible to the public to display public information materials and the Repair Watch Public Report?

Yes

Describe the area

8. It is the station owner's responsibility to ensure the station operation as proposed all complies with required local zoning, OSHA, fire and safety requirements, in addition to emissions facility requirements. Does the proposed facility meet these requirements?

Yes

9. Does the station owner/manager understand quality assurance audits are required and station personnel are required to assist EPD and GCAF auditors in performing audits? Failure to assist in audits is a violation of the I/M rules and will result in the station failing the audit and may be possibly subject to EPD enforcement action.

Yes

Attach Files (7 required)

Current years' business license

Current W-9 for the business

Certificate of Liability Insurance.

Photo ID (Driver's License/State ID) - required from the station owner only

Verification of Lawful Presence with the United States - this form must be notarized

Site plan drawing

Documentation from your Internet service provider, including the static IP address.

If your service provider has not provided you with proof of your static IP address, your certification or re-certification application may be delayed.

Attach Another File

SECTION G – CONFIRMATIONS & SIGNATURE

I/We have read and understand all of the rules of Chapter 391-3-20 of the Georgia Department of Natural Resources Environmental Protection Division, Enhanced Inspection and Maintenance, and in the Enhanced Inspection and Maintenance Test Equipment, Procedures, and Specifications Manual.