Fillable STAR STATION CERTIFICATION APPLICATION BUREAU OF AUTOMOTIVE REPAIR (California)

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STAR STATION CERTIFICATION APPLICATION BUREAU OF AUTOMOTIVE REPAIR (California)

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BUSINESS, CONSUMER SERVICES, AND HOUSING AGENCY • GAVIN NEWSOM, GOVERNOR
BUREAU OF AUTOMOTIVE REPAIR | LICENSING PROGRAM
10949 North Mather Boulevard, Rancho Cordova, CA 95670
P (855) 735-0462 F (888) 421-7798 F (916) 464-1972 | www.smogcheck.ca.gov
STAR STATION CERTIFICATION APPLICATION
NO FEE REQUIRED
STATION TYPE: Test-Only Test and Repair
STATION NAME
PHONE NUMBER
(include area code)
STREET ADDRESS
CITY STATE ZIP CODE
E-MAIL ADDRESS
STATION LICENSE NUMBER
OWNERSHIP TYPE: Sole Proprietor Partnership LP LLC Corp - Name & No:
Please answer the following questions. If “yes,” attach additional page(s) with written explanation.
Have you or any of your partners, corporate ocers, trustees, members, or any station managers or technician(s):
1. Ever been convicted of a crime related to the Smog Check Program or Automotive Repair Act?
Yes No
2. Ever had any license denied, suspended, revoked, or placed on Probation by the Bureau of
Automotive Repair?
Yes No
3. Ever been found liable in a civil proceeding for any act or any omission related to the license
of an Automotive Repair Dealer, Smog Check station, or Smog Check technician?
Yes No
4. Have you ever been issued a Smog Check citation by the Bureau of Automotive Repair
that became eective within the last year?
Yes No
CERTIFICATION
I/we hereby request and acknowledge that if, at any time after becoming certied under the STAR Program the Follow-up Pass Rate score for any
technician employed by the station drops below the minimum acceptable standard of 0.1, then that technician will be automatically removed by the
Bureau from all of my/our station’s EIS Technician Information Tables, and not allowed to perform Smog Check inspections or repairs at my/our STAR
certied station until the technician meets the STAR Program requirements.
Yes No
SIGNATURE REQUIREMENTS
• If SOLE PROPRIETORSHIP, the owner must sign. • If CORPORATION, at least one corporate ocer must sign.
• If PARTNERSHIP or LP, all partners must sign. • If LLC, all members must sign.
[attach additional page(s) if necessary]
FULL NAME: First Middle Last TITLE:
SIGNATURE:
(partners and members of a LP/LLC must sign) DATE:
FULL NAME:
First Middle Last
TITLE:
SIGNATURE:
(partners and members of a LP/LLC must sign) DATE:
FULL NAME: First Middle Last TITLE:
SIGNATURE:
(partners and members of a LP/LLC must sign) DATE:
MAIL YOUR APPLICATION TO:
Bureau of Automotive Repair
Licensing Unit
10949 N. Mather Blvd.
Rancho Cordova, CA 95670 or FAX TO: 888.421.7798 or 916.464.1974
FOR BUREAU USE ONLY
ENHANCED AREA STATION
BASIC AREA STATION
CHANGE OF OWNERSHIP AREA STATION
MET STAR PERFORMANCE REQUIREMENTS
YES
NO
INITIAL
DATE
PASSED ENFORCEMENT RECORD CHECK
YES
NO
INITIAL
REAPPLY DATE
DATE
FINAL APPROVAL
YES
NO
INITIAL
DATE
NOTICE ON COLLECTION OF PERSONAL INFORMATION
COLLECTION AND USE OF PERSONAL INFORMATION
The Bureau of Automotive Repair of the Department of Consumer Affairs collects the personal information requested on
this form as authorized by Business and Professions Code sections 30, 9884, and 9887.2, Labor Code section 432.7,
Civil Code section 1798 et seq. (Information Practices Act), Health and Safety Code section 44002, and California Code
of Regulations, title 16, section 3392.3.1. The Bureau of Automotive Repair uses this information principally to identify and
evaluate applicants for licensure, issue and renew licenses, and enforce licensing standards set by law and regulation.
Pursuant to Business and Professions Code section 27, the licensee's address of record is a public record and will be
posted on BAR's website.
MANDATORY SUBMISSION
Submission of the requested information is mandatory. The Bureau of Automotive Repair cannot consider your application
for licensure or renewal unless you provide all requested information.
ACCESS TO PERSONAL INFORMATION
You may review the records maintained by the Bureau of Automotive Repair that contain your personal information, as
permitted by the Information Practices Act. See below for contact information.
POSSIBLE DISCLOSURE OF PERSONAL INFORMATION
The Bureau of Automotive Repair makes every effort to protect the personal information you provide us. The information
you provide, however, may be disclosed in the following circumstances:
• In response to a Public Records Act (PRA) request (Government Code section 6250 et seq., as allowed by the
Information Practices Act (Civil Code section 1798 et seq.);
• To another government agency as required by State or Federal law; or,
• In response to a court or administrative order, a subpoena, or a search warrant.
Effective July 1, 2012, the California Department of Tax and Fee Adminstration and the Franchise Tax Board may share
taxpayer information with this agency:
• Your
license may be suspended by BAR if your state tax obligation is not paid
CONTACT INFORMATION
F
or questions about this notice or access to your records, you may contact the Bureau of Automotive Repair PRA Unit at
10949 North Mather Boulevard, Rancho Cordova, CA 95670, by phone at (855) 735-0465, or by email at
bar.pra@dca.ca.gov.
F
or questions about the Department’s Privacy Policy, you may contact the Department of Consumer Affairs at 1625 North
Market Boulevard, Sacramento, CA 95834, by phone at (800) 952-5210, or by email at
dca@dca.ca.gov.
For questions about the Information Practices Act, you may contact the Office of the Attorney General, California
Department of Justice - Attention: Public Inquiry Unit, PO Box 944255, Sacramento, CA 94244, by phone at (800) 952-
5225, or online at
www.privacy.ca.gov.
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STAR STATION CERTIFICATION APPLICATION BUREAU OF AUTOMOTIVE REPAIR (California)

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Completed 15 October 2020

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