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Home My WebLink Aboutbocc.con.048.2001 i CONTRACT # QLO�- :�-oO / PITKIN COUNTY AMBULANCE LICENSE FOR: ASPEN AMBULANCE DISTRICT MEDIC 3, MEDIC 4, MEDIC 5, MEDIC 6 GRANT OF LICENSE/PERMIT The undersigned, representing the Board of County Commissioners of Pitkin County, Colorado, do hereby grant a license to the above named applicant to provide ambulance service within Pitkin County. This license shall have upon it any restrictions listed 1 below, shall be granted any waivers listed below, and shall be valid for the dates listed below, unless revoked by the Board pursuant to the provisions of Pitkin County Resolution No. 87-7 and any applicable laws of the State of Colorado. r RESTRICTIONS: None WAIVERS GRANTED: None THIS LICENSE IS VALID FROM: January 1, 2001 UNTIL DECEMBER 31, OF THE SAME CALENDAR YEAR J l � ` - l`/'/'� L APPROVED BY BOCC Mick Ireland, Chairperson ON Al-�L5—"O Pitkin County Board of County Commissioners IPITKIIV COUNTY APPLICATION FOR AMBULANCE SERVICE LICENSE GENERAL INFORMATION Ambulance Service Name: A.sa%i=hA Amn" Lra-4cr.- 17.sm. o i Doing Business As: (�A Cam o4 P\ca1\N Office Address: un N'50C�4 Vra"h <,sQNrrL C4q- t Asnwl C--. Si\, ti STRE�r/PO CITY STATE ZI CODE `9'1 aB�X (`l1 Q) fasiwf. r,� Office Communications: *5`t-4 — t 58 n 544— i s-t l C It. ( , (y Car- VOICE FAX E-MAIL [NTERNEr SERVICE INFORMATION Service Area: -Af-n n.s t,�,c ��sTri.c.—d'Xy voA7* ce Director: IIIciArl W ra txc ;c Service Type: PUBLIC PRIVATE_ BLS_ ALS__& EMERGENT 'k, TRANSFER_ X SPECIAL EVENfS�_ Number of Ambulances Licensed: 4 PHYSICIAN ADVISOR INFORMATION hysician Advisor Name: Da, Cava, *Colorado License Number: 3 r,9 3 Office Address: U o fASaest V!k\ian KQ%f cr. G`to( "57rL` 'M t v RQ- STREEr/PO BOX CITY STATE ZIP CODE Ccl7� ) (tii3) �►��+a ice Communication: -5,4-t— t3,j A 3u,4— t35�c e V-4 Ni.,c VOICE FAX E-MAIL INTERNET I hereby certify that the information provided in this application is true to the best of my knowledge and belief and contains no willful misrepresentation or falsification. Determination that an Ambulance Service License has been issued based on false information constitutes grounds for license revocation,suspension of operations and possible criminal pr sec tion. �- Q/ / /,sera is jz. 't 110 f o i x n, n �l o SE ICE DIRECTOR'S SIGNATURE DATE PHYSI ADVIS9 SIGNAT DA (FOR EMS COUNCIL USE ONLY) Date Received: L} l- I o I Ambulance Permits Attached:T EMS Council Comments: n a EMS Council Recommendation: p sacs a. �+ u. lc n. ,rE PrNn t .cnTAa EMS Council Chairperson Signature: —.- / NAME DATE Date Referred to BOCC: y--�2j-Oj BoCC Action: h h"13 06',C O Date: Mez,o:c_ 3 Pmmw COUNTY APPLICATION / FOR AMBULANCE VEHICLE PERMIT SERVICE INFORMATION Ambulance Service Name: R spy -A.ryN n s\.NeAs-mko-x Office Address: q o (>yndl 4 N%i r;j.. tLV o mat oIlr F \ Cla�r\u-Cas- Y--3 Asp C=, .L l I,t I STREET/PO BOX CITY STATE ZIP CODE Q91 .) Vvi c) A> a Office Communications: -s-A-; - t 5tc, 5�k'-t- ,5-1 3 L V,�k.%4ar VOICE FAX E-MAIL INTERNET ,HICLE INFORMATION Designation: to Mt lig,ZLicense Plate: d L5 ra,S 1 VIN: I GBT K 3 tjJ e.d Fo 3`11: o Chassis Year: k 19 1 Make: CtX Type: I _2�_ II _ III_ 4x4: yes�& no Insurance Company: RotiaL �tdb�mnl tc l �, Policy Number: RN7Sfjo 135--ot Expiration: t c� Vehicle Location: :_ AMGv spv CINsr\'s Cz�.V--u +� M&*%*4 CQ a L'% t STREET/PO BOX - CrIY STATE f ZIP CODE �!EQIJEST FOR WAIVER(include reason for request) r SERVIC DIRECTOR'S SIGNATURE DATE (FOR AMBULANCE INSPECTOR'S USE ONLY) Clear CCIC: Clear NCIC: Insurance Card Present: Registration Card Present: ✓ Permit Fee Attached I Basic Life Support Required Equipment List Attached Lam, Mechanical Condition Certification Attached Advance Life Support Provider Required Equipment Certification Attached Comments/Recommendation: 1 ,ntc��e 1 J ��—_ �VlPo1l C.:_t (ec-�„��Y-c- `�i,c, i=�;� y -I"Li•- C?I INSPECTOR'S SIGNATURE POSITION DATE PITKIN COUNTY ADVANCED LIFE SUPPORT PROVIDER REQUIRED EQUIPMENT CERTIFICATION Ambulance Service Name: pis-m-,zrAmbulanceDesignation: M ,c REQUIRED ALS FQIJTPMENT 1. All equipment and supplies listed on the Basic Life Support Required Equipment List. 2. Pediatric diagnostic equipment, age/weight/vital signs chart and drug dosage/equipment size list. ' Adult, pediatric and neo-natal vascular access supplies and equipment as authorized in medical protocols approved for this ambulance service. 4. Adult, pediatric and neo-natal endotracheal intubation equipment as authorized in medical protocols approved for this ambulance service. 5. Cardiac monitor/defibrillator with printer and adult and pediatric monitoring and defibrillating capabilities as authorized in medical protocols approved for this ambulance service. Pharmacological agents and administration equipment and supplies as authorized in medical protocols approved for this ambulance service. ' J 7. Any additional equipment and supplies needed to perform other procedures as authorized in medical protocols approved for this ambulance service. As Physician Advisor for Disrnkt — I certify that this ambulance carries the equipment and supplies listed above and meets the minimum requirements, established by the State of Colorado and Pitkin County, to provide medical care and transportation of the sick and injured at the Advanced Life Support level. Provision of Advanced Life Support is limited as described in 3-CCR-713-6, Section 4 "Medical Acts Allowed EMTs and Paramedics." 30993 PHYSICIAN' ADVIS S SIGNAT COLORADO MEDICAL LICENSE NUMBER DATE PITKIIV COUNTY VEHICLE SAFETY AND OPERABILITY CERTIFICATION Ambulance Service Name: ' >L> t/1ow,39NO'�E-License Plate: Ambulance Number: J SYSTEMS ACCEPTABLE NOT ACCEPTABLE COMMENTS Wheels & Tires eenng Alignment Suspension Service Brakes Parking Brake ✓ Driving Lights Visual Warning Systems ✓ � Audible Warning Systems Electrical System �x ust System v Fuel System Glass, Mirrors Body & Sheet Metal LZ I, ta- professing to be a motor vehicle mechanic with training in all of the systems listed above, have eva ted the condition of these systems on the ambulance indicated above and have determined this ambulance to be in safe operating condition. This evaluation does not warrantee the future safety and/or operability of this ambulance due to conditions beyond my control. �Tr-' ✓ c/� c� rrsr'�i F MECHANIC'S NAME AGENCY/C MPANY PHONE NUMBER TE PITKM COUNTY BASIC LIFE SUPPORT REQUIRED EQUIPMENT LIST SAFETY F.OUIP_ MFNT V One 2-1/2 lb. or larger ABC fire extinguisher, accessible from the patient compartment and having been serviced within the last year per NFPA 10 Section 4. One 5 lb. or larger ABC fire extinguisher, accessible from outside the vehicle and having been serviced within the last year per NFPA 10 Section 4.. Two "NO SMOKING-OXYGEN IN USE" signs, one in cab and one in patient compartment. fSlashlight, 2-D cell equivalent or better with spare bulb and batteries or charger. et of 3 reflective warning devices. One reflective vest, coat or equivalent for each member of the crew normally assigned. At least one "SHARPS" container, clearly labeled and easily accessible in the patient compartment. t/Restraining devices for all items not in a securable cabinet I, EMERGENCY WARNING F,QUIPMFNT v Audible warning device (siren) with at least 2 different tones. Li"Visual warning devices (lights) with alternating red and/or blue flashing or rotating visible from all sides simultaneously and clear flashing or oscillating visible from front. I COMMUNICATIONS FO IPM *r'*' Mobile VHF radio with appropriate State, Pitkin County arffi individual agency frequencies. J ✓ Mobile UHF radio with appropriate State, Pitkin County, hospital and individual agency frequencies. —�Portable radio with charger and/or cellular phone for back-up communications with dispatch and hospitals. i iFDIC AI. EQUIPMENT AND SjjPPT IFS Airway: Fixed suction system with wide bore tubing, rigid pharyngeal curved suction tip and soft catheter suction tip with sizes from 5 Fr. to 14 Fr. Portable suction system with wide bore tubing,rigid pharyngeal curved suction tip and soft catheter suction tip with sizes from 5 Fr. to 14 Fr. V"Bulb Syringe. Nasopharyngeal airways in pediatric and adult sizes. Oropharyngeal airways in pediatric and adult sizes. V Bite stick or equivalent (oropharyngeal airway). t , Fixed oxygen system with a minimum storage capacity of 125 cubic feet (M cylinder) and a minimum delivery capability for three patients simultaneously at flows of at least 1-15 LPM. (/Portable oxygen system with a minimum storage capacity of 15 cubic feet (D cylinder) and a minimum delivery capability for one patient at flows of at least 1-15 LPM. Infant Bag-Valve-Mask with 500cc bag, reservoir and newborn, infant and child masks. J t,-'Adult Bag-Valve-Mask with 1000cc bag, reservoir and adult mask. "All mask attachments must be 15mm"" y Oxygen masks and cannulas capable of delivering oxygen to adults and infants at flows of at least 1-15 LPM. I PITKIIV COUNTY BASIC LIFE SUPPORT REQUIRED EQUIPMENT LIST M .DI A . FQIJTPMFNT AND SUPPLIES Diagnostic: y"Blood pressure cuffs in large adult, regular adult, child, infant and neonatal sizes. t.i Stethoscopes in adult and pediatric sizes. ✓Pulse oximeter with adult and pediatric sensors. Immobilization & Splinting: tr"One lower extremity traction splint. tJ Upper and lower extremity splints of any type (vacuum, air, SAM, wire, board, etc.). Long spineboard, vacuum mattress or equivalent with appropriate accessories to immobilize patients from head to heels. V "One orthopedic stretcher(scoop). ✓Short spineboard, KED or equivalent with appropriate straps to immobilize patients from head to pelvis. ediatric spineboard or adult spineboard adaptable to pediatric use. Adult and pediatric sized head immobilization equipment for each long spineboard and/or scoop stretcher carried. Rigid cervical immobilization collars in tall adult through infant sizes. Wo' Care: V, Bandages, including but not limited to, roller gauze,triangular and elastic per agency needs. Dressings, including but not limited to, trauma, ABD, gauze rocclusive and bandaids per agency needs. Sterile bum sheets. Povidone and alcohol swabs or equivalent. v Adhesive tape, including but not limited to, 1" and 2" per agency needs. Li Sterile irrigation solution. ostetrical Supplies: Sterile OB kit to include: towels, 4x4s, umbilical tape or cord clamps, scissors, bulb syringe, sterile blanket and sterile gloves. V Silver Swaddler and stocking cap or equivalents. Infection Control: 'Exam gloves in small, medium and large sizes. Face and eye shields. t Fluid-proof gowns with full length sleeves or equivalent. F'Disinfectant spray or wipes for personnel and equipment. Miscellaneous: Oral glucose. ✓Activated charcoal. V Heavy duty bandage scissors or shears capable of cutting clothing, belts, boots, etc. ✓Spill-proof emesis container with at least 1 liter capacity. L, yniversal or separate male and female urinals. Multi-level.wheeled gurney 77' Stair chair or equivalent. --- Blankets. —� Patient compartment heater. 2 PITKIIV COUNTY APPLICATION FOR AMBULANCE VEHICLE PERMIT SERVICE INFORMATION Ambulance Service Name: A Office Address: c1;; IAsr i bi 4 ram , tA. a p„,%" oL-v I CASrI,:c-, cry.-max Pia- A +�+ Ca 2 y1 STREETIPP BOX C9l'z CITY STATE ZI CODE `5 -I 1) ` AS Peel lvM, Office Communications:_ s-tA i�, Q 91-4 N—:r VOICE FAX E-MAIL INTERNET MICLE INFORMATION Mcn�t.•} cz L.--P \rx,rl Designation: H O,4t EI icense Plate: VIN: 1 C�C3 N J 3'1 A a v-fr 3-7 t'I) Chassis Year: 19 g`t— Make: CI;E=P Type: I � II — III— 4x4: yes� no_ Insurance Company: Roy at_I ash,a:cVl cb. Policy Number: Rw]- oy� t 3 5--�I Expiration: I I I Ia t^ Vehicle Location: :4kM D. II sac .— G'tL�+r+cE„ Cs`t� 3 CAST L..- C'ra < A`�°�y C iy i t.:l I STREETIPO BOX ' 7 CITY STATE ZIP CODE �!EQITEST FOR WAIVER (include reason for request) , SERVICE RECTOR'S SIGNATURE v DATE (FOR AMBULANCE INSPECTOR'S USE ONLY) Clear CCIC: Clear NCIC: Insurance Card Present: Registration Card Present: `— Permit Fee Attached l/ Basic Life Support Required Equipment List Attached Mechanical Condition Certification Attached Advance Life Support Provider Required Equipment Certification Attached Comments/Recommendation: INSPECTOR'S SIGNATURE POSITION DATE PITKIN COUNTY ADVANCED LIFE SUPPORT PROVIDER REQUIRED EQUIPMENT CERTIFICATION Ambulance Service Name: D„m,,r--Ambulance Designation: m ��•� REQUIRED ALS EQUIPMENT 1. All equipment and supplies listed on the Basic Life Support Required Equipment List. 2. Pediatric diagnostic equipment, age/weight/vital signs chart and drug dosage/equipment size list. ' Adult, pediatric and neo-natal vascular access supplies and equipment as authorized in medical protocols approved for this ambulance service. 4. Adult, pediatric and neo-natal endotracheal intubation equipment as authorized in medical protocols approved for this ambulance service. 5. Cardiac monitor/defibrillatur with printer and adult and pediatric monitoring and defibrillating capabilities as authorized in medical protocols approved for this ambulance service. Pharmacological agents and administration equipment and supplies as authorized in medical protocols approved for this ambulance service. ° 7. Any additional equipment and supplies needed to perform other procedures as authorized in medical protocols approved for this ambulance service. As Physician Advisor for I certify that this ambulance carries the equipment and supplies listed above and meets the-minimum requirements, established by the State of Colorado and Pitkin County, to provide medical care and transportation of the sick and injured at the Advanced Life Support level. Provision of Advanced Life Support is limited as described in 3-CCR-713-6, Section 4 "Medical Acts Allowed EMTs and Paramedics." PHYSICI ADV(S S S GNATUaV COLORADO MEDICAL LICENSE NUMBER DATE PITKIIV COUNTY l VEHICLE SAFETY AND OPERABILITY CERTIFICATION Ambulance Service Name: - (1 Ld� License Plate: Ambulance Number: SYSTEMS ACCEPTABLE NOT ACCEPTABLE COMMENTS Wheels & Tires eering Alignment Suspension Service Brakes Parking Brake 1✓ Driving Lights Visual Warning Systems L/ Audible Warning Systems Electrical System xhaust System Fuel System I/ Glass, Mirrors Ll Body & Sheet Metal I, L 4/-Y11 WC f, professing to be a motor vehicle mechanic with training in all of the systems listed above, have evaluated the condition of these systems on the ambulance indicated above and have determined this ambulance to be in safe operating condition. This evaluation does not warrantee the future safety and/or operability of this ambulance due to conditions beyond my control. ,1' ;"'a ZL 77h� )) 3 2.1 4YL i q7o -qA (y / M NIC'S NAME AGENCY4tOMPANY l PHONE NUMBER DA E ' PrrxIvcouNrY BASIC LIFE SUPPORT �I REQUIRED EQUIPMENT LIST SAFFTY PMFNT One 2-1/2 lb. or larger ABC fire extinguisher, accessible from the patient compartment and having been kXserviced within the last year per NFPA 10 Section 4. One 5 lb. or larger ABC fire extinguisher, accessible from outside the vehicle and having been serviced ..;within the last year per NFPA 10 Section 4.. Two "NO SMOKING-OXYGEN IN USE" signs, one in cab and one in patient compartment. " Flashlight, 2-D cell equivalent or better with spare bulb and batteries or charger. tZ Set of 3 reflective warning devices. One reflective vest, coat or equivalent for each member of the crew normally assigned. At least one "SHARPS" container, clearly labeled and easily accessible in the patient compartment. I "Restraining devices for all items not in a securable cabinet I EMERGENCY WARNING EQUIPMENT Lr Audible warning device (siren) with at least 2 different tones. t/Visual warning devices (lights) with alternating red and/or blue flashing or rotating visible from all sides i simultaneously and clear flashing or oscillating visible from front. I COMMUNICATIONS EQUIPMENT L,- _ Mobile VHF radio with appropriate State, Pitkin County acid individual agency frequencies. l ✓ Mobile UHF radio with appropriate State, Pitkin County, hospital and individual agency frequencies. Portable radio with charger and/or cellular phone for back-up communications with dispatch and hospitals. 1EDICA I FOL)IPMFNT SUPPURS p I Airway: C'Fixed suction system with wide bore tubing, rigid pharyngeal curved suction tip and soft catheter suction tip with sizes from 5 Fr. to 14 Fr. y Portable suction system with wide bore tubing, rigid pharyngeal curved suction tip and soft catheter suction tip with sizes from 5 Fr. to 14 Fr. ✓Bulb Syringe. ✓Nasopharyngeal airways in pediatric and adult sizes. Oropharyngeal airways in pediatric and adult sizes. Bite stick or equivalent (oropharyngeal airway). ✓Fixed oxygen system with a minimum storage capacity of 125 cubic feet (M cylinder) and a minimum delivery capability for three patients simultaneously at flows of at least 1-15 LPM. t/Portable oxygen system with a minimum storage capacity of 15 cubic feet (D cylinder) and a minimum delivery capability for one patient at flows of at least 1-15 LPM. Infant Bag-Valve-Mask with 500cc bag, reservoir and newborn, infant and child masks. Adult Bag-Valve-Mask with 1000cc bag, reservoir and adult mask. "Ail mask attachments must be 15mtn•" J Oxygen masks and cannulas capable of delivering oxygen to adults and infants at flows of at least 1-15 LPM. 1 PITKIN COUNTY I BASIC LIFE SUPPORT REQUIRED EQUIPMENT LIST MEDICAL. EOUIPMENT AND SUPPLIES Diagnostic: Mood pressure cuffs in large adult, regular adult, child, infant and neonatal sizes. Mood in adult and pediatric sizes. Pulse oximeter with adult and pediatric sensors. Immobilization & Splinting: ,One lower extremity traction splint. Upper and lower extremity splints of any type (vacuum,air, SAM, wire, board, etc.). v Long spineboard, vacuum mattress or equivalent with appropriate accessories to immobilize patients from head to heels. Li One orthopedic stretcher(scoop). k---'Short spineboard, KED or equivalent with appropriate straps to immobilize patients from head to pelvis. _/.Pediatric spineboard or adult spineboard adaptable to pediatric use. Adult and pediatric sized head immobilization equipment for each long spineboard and/or scoop stretcher carried. t/�igid cervical immobilization collars in tall adult through infant sizes. Wound Care: t/Bandages, including but not limited to, roller gauze, triangular and elastic per agency needs. Dressings, including but not limited to, trauma, ABD, gauzerocclusive and bandaids per agency needs. k- Sterile bum sheets. —U�7 Povidone and alcohol swabs or equivalent. Lam'Adhesive tape, including but not limited to, 1" and 2"per agency needs. _✓Sterile irrigation solution. ,bsteincal Supplies: Sterile OB kit to include: towels, 4x4s, umbilical tape or cord clamps, scissors, bulb syringe, sterile blanket and sterile gloves. Silver Swaddler and stocking cap or equivalents. Infection Control: I/Exam gloves in small, medium and large sizes. L Face and eye shields. 'Fluid-proof gowns with full length sleeves or equivalent. L,"` Disinfectant spray or wipes for personnel and equipment. Miscellaneous: v" Oral glucose. Activated charcoal. "✓"Heavy duty bandage scissors or shears capable of cutting clothing, belts, boots, etc. L-7'Spill-proof emesis container with at least 1 liter capacity. L✓ universal or separate male and female urinals. /tMulti-level.wheeled gurney -_ Stair chair or equivalent. ' Blankets. —�Patient compartment heater. 2 PFrKm COUNTY APPLICATION FOR AMBULANCE VEHICLE PERMIT SERVICE INFORMATION Ambulance Service Name: N 5%d.+ -A^n3.j was s rsa.c Office Address: go r-,u& W- -1 cap F cr> Itn -Rsn STREET/PO BOX CITY STATE ZIP CODE C51c) �(y-T Asps�l.My Office Communications: VOICE FAX E-MAIL INTERNET 'HI L.E INFORMATION Mtso-,� 7 C: ", f,m A Designation: c,,s .r License Plate: `i 8-A A 3 cs VIN: I Cr 1*5 K 3`i A Z R E. L\S'i y a Chassis Year: 1(I 9 -A Make: Q At=i Type: I )( II _ III_ 4x4: yes y, no_ Insurance Company: R�aL INaI�MwN.T4 c'.... Policy Number: RA-4 Expiration: 1 1 Vehicle Location: : *jar,-Tikap$ 14401 STREETIPO BOX CITY STATE ZIP CODE !RQIJEST FOR WAIVER(include reason for request) P , ._ lA�f�Llccy2J AI /"� SERVICE SIGNATURE DATE DIRECTOR'S (FOR AMBULANCE INSPECTOR'S USE ONLY) Clear CCIC: Clear NCIC: Insurance Card Present: L—' Registration Card Present: L` ✓ Permit Fee Attached 1— Basic Life Support Required Equipment List Attached Mechanical Condition Certification Attached Advance Life Support Provider Required Equipment Certification Attached Comments/Recommendation: INSPECTOR'S SIGNATURE POSITION DATE PrrniV COUNTY Iq ADVANCED LIFE SUPPORT PROVIDER REQUIRED EQUIPMENT CERTIFICATION Ambulance Service Name: A sr d 1 Designation: RF. UI M ALS FOUTPMENT 1. All equipment and supplies listed on the Basic Life Support Required Equipment List. 2. Pediatric diagnostic equipment, age/weight/vital signs chart and drug dosage/equipment size list. ' Adult, pediatric and neo-natal vascular access supplies and equipment as authorized in medical protocols approved for this ambulance service. 4. Adult, pediatric and neo-natal endotracheal intubation equipment as authorized in medical protocols approved for this ambulance service. 5. Cardiac monitor/defibrillator with printer and adult and pediatric monitoring and defibrillating capabilities as authorized in medical protocols approved for this ambulance service. Pharmacological agents and administration equipment and supplies as authorized in medical protocols approved for this ambulance service. r J 7. Any additional equipment and supplies needed to perform other procedures as authorized in medical protocols approved for this ambulance service. As Physician Advisor for (3 SV ZA I certify that this ambulance carries the equipment and supplies listed above and meets the,minimum requirements, established by the State of Colorado and Pitkin County, to provide medical care and transportation of the sick and injured at the Advanced Life Support level. Provision of Advanced Life Support is limited as described in 3-CCR-713-6, Section 4 "Medical Acts Allowed EMTs and Paramedics." 9 3 J-(L PHYSICIAN'A VISOR' GNA RE COLORADO MEDICAL LICENSE NUMBER DATE � 5 PrrxLIv COUNTY VEHICLE SAFETY AND OPERABILITY CERTIFICATION Ambulance Service Name: uy License Plate: Ambulance Number. M SYSTEMS ACCEPTABLE NOT ACCEPTABLE COMMENTS Wheels & Tires t/ eering t/ Alignment Suspension Service Brakes Parking Brake Driving Lights i/ Visual Warning Systems ✓ y� ,. Audible Warning Systems Electrical System V �xhaust System v Fuel System Glass, Mirrors v Body& Sheet Metal u-c-a q professing to be a motor vehicle mechanic with training in all of the systems listed above, have evaluated the condition of these systems on the ambulance indicated above and have determined this ambulance to be in safe operating condition. This evaluation does not warrantee the future safety and/or operability of this ambulance due to conditions beyond my control. y rt-� Ii07iG'LVL 0 ..Gj' ._ la 5— 3 C� MECHANIC'S NAME A NCY/COMPANY PHONE NUMBER DATE f'ITKIN COUNTY s BASIC LIFE SUPPORT REQUIRED EQUIPMENT LIST One 2-1/2 lb. or larger ABC fire extinguisher, accessible from the patient compartment and having been serviced within the last year per NFPA 10 Section 4. L' One 5 lb. or larger ABC fire extinguisher, accessible from outside the vehicle and having been serviced within the last year per NFPA 10 Section 4.. Lr"Two "NO SMOKING-OXYGEN IN USE" signs, one in cab and one in patient compartment. L-.--Flashlight, 2-13 cell equivalent or better with spare bulb and batteries or charger. Set of 3 reflective warning devices. 1 -" One reflective vest, coat or equivalent for each member of the crew normally assigned. t— At least one "SHARPS" container, clearly labeled and easily accessible in the patient compartment. L--'Restraining devices for all items not in a securable cabinet EMERGENCY WARNING EQUIPMENT Audible warning device (siren) with at least 2 different tones. 7 Visual warning devices (lights) with alternating red and/or blue flashing or rotating visible from all sides simultaneously and clear flashing or oscillating visible from front. COMMUNICATIONS EQUIPMENT ice' Mobile VHF radio with appropriate State, Pitkin County an¢individual agency frequencies. ✓` Mobile UHF radio with appropriate State, Pitkin County, hospital and individual agency frequencies. Portable radio with charger and/or cellular phone for back-up communications with dispatch and hospitals. MEDICAL EQUIPMENT AND SUPPLIES Ai" " Fixed suction system with wide bore tubing, rigid pharyngeal curved suction tip and soft catheter suction j tip with sizes from 5 Fr. to 14 Fr. Portable suction system with wide bore tubing, rigid pharyngeal curved suction tip and soft catheter suction tip with sizes from 5 Fr. to 14 Fr. L--'Bulb Syringe. v Nasopharyngeal airways in pediatric and adult sizes. Oropharyngeal airways in pediatric and adult sizes. L ' Bite stick or equivalent (oropharyngeal airway). _ Fixed oxygen system with a minimum storage capacity of 125 cubic feet (M cylinder) and a minimum delivery capability for three patients simultaneously at flows of at least 1-15 LPM. Portable oxygen system with a minimum storage capacity of 15 cubic feet (D cylinder) and a minimum delivery capability for one patient at flows of at least 1-15 LPM. L/Infant Bag-Valve-Mask with 500cc bag, reservoir and newbom, infant and child masks. L, Adult Bag-Valve-Mask with I000cc bag, reservoir and adult mask. "All mask attachments must be 15mm'• Oxygen masks and cannulas capable of delivering oxygen to adults and infants at flows of at least 1-15 LPM. I IPITKm COUNTY 11 BASIC LIFE SUPPORT REQUIRED EQUIPMENT LIST MEDICAL .Q IPM .NT AND SUPPLIES Diagngstic: ' Blood pressure cuffs in large adult, regular adult, child, infant and neonatal sizes. ✓ Stethoscopes in adult and pediatric sizes. Pulse oximeter with adult and pediatric sensors. Immobilization & Splinting: One lower extremity traction splint. v Upper and lower extremity splints of any type (vacuum, air, SAM, wire, board, etc.). t, Long spineboard, vacuum mattress or equivalent with appropriate accessories to immobilize patients from head to heels. One orthopedic stretcher(scoop). V? Short spineboard, KED or equivalent with appropriate straps to immobilize patients from head to pelvis. —7 Pediatric spineboard or adult spineboard adaptable to pediatric use. V Adult and pediatric sized head immobilization equipment for each long spineboard and/or scoop stretcher carried. Rigid cervical immobilization collars in tall adult through infant sizes. Wound Care: Bandages, including but not limited to, roller gauze,triangular and elastic per agency needs. 'Dressings, including but not limited to, trauma, ABD, gauze,*occlusive and bandaids per agency needs. V Sterile bum sheets. Povidone and alcohol swabs or equivalent. Adhesive tape, including but not limited to, 1" and 2"per agency needs. L-''Sterile irrigation solution. ,bstetrical Supplies: Sterile OB kit to include: towels, 4x4s, umbilical tape or cord clamps, scissors, bulb syringe, sterile blanket and sterile gloves. L-' Silver Swaddler and stocking cap or equivalents. Infection Control: L" Exam gloves in small, medium and large sizes. �' Face and eye shields. Fluid-proof gowns with full length sleeves or equivalent. ✓ Disinfectant spray or wipes for personnel and equipment. Miscellaneous: t- Oral glucose. t/ Activated charcoal. �. Heavy duty bandage scissors or shears capable of cutting clothing, belts, boots, etc. Spill-proof emesis container with at least 1 liter capacity. tom- universal or separate male and female urinals. Multi-level.wheeled gurney l L'Stair chair or equivalent. J t-Blankets. —T�Patient compartment heater. 2 M�a1 c- PITKIN COUNTY APPLICATION FOR AMBULANCE VEHICLE PERMIT SERVICE INFORMATION Ambulance Service Name: a'pto Office Address: Cl- d . o o v�y- STREET/PO BOX E3 CITY STATE ZIP CODE (g I Office Communications: -ti v - 16 -1 s'1 iL- � he �_► ar VOICE FAX E-MAIL INTERNET HICLE INFORMATION C—L> -. V%rxt-4 Designation: IWo rarer s License Plate: ye s w N VIN: 1. 3 la Fa r—44 ya i-L Chassis Year: 1 c Make: t ;,�n o J' w,s Type: I_ II_ III_)L_ 4x4: yes 1, no_ Insurance Company: 1Z--JAB 1 nl ;� N, , C _ Policy Number:__!Z wS oho t 3 -of Expiration: I 1 0 ,_. Vehicle Location: :�.g,,f,.,.:,,, A J, it ' rZMTIQA 134 - 3 [gyr(`Cnc�t z_ R � STREET/PO BOX �T CrTY STATE P CODE �'EQUEST FOR WAIVER (include reason for request) SERVICE DIRECTOR'S SIGNATURE DATE (FOR AMBULANCE INSPECTOR'S USE ONLY) Clear CCIC: Clear NCIC: Insurance Card Present: t: ' Registration Card Present: G. Permit Fee Attached L Basic Life Support Required Equipment List Attached t Mechanical Condition Certification Attached Advance Life Support Provider Required Equipment Certification Attached Comments/Recommendation: INSPECTOR'S SIGNATURE POSITION DATE :PITKIN COUNTY f q ADVANCED LIFE SUPPORT PROVIDER I REQUIRED EQUIPMENT CERTIFICATION Ambulance Service Name: Q ym�ejt— Ambulance Designation: Me—ync- REQUIRED AL.S EQUIPMENT 1. All equipment and supplies listed on the Basic Life Support Required Equipment List. 2. Pediatric diagnostic equipment, age/weight/vital signs chart and drug dosage/equipment size list. Adult, pediatric and neo-natal vascular access supplies and equipment as authorized in medical protocols approved for this ambulance service. 4. Adult, pediatric and neo-natal endotracheal intubation equipment as authorized in medical protocols approved for this ambulance service. 5. Cardiac monitor/defibrillator with printer and adult and pediatric monitoring and defibrillating capabilities as authorized in medical protocols approved for this ambulance service. Pharmacological agents and administration equipment and supplies as authorized in medical protocols approved for this ambulance service. 7. Any additional equipment and supplies needed to perform other procedures as authorized in medical protocols approved for this ambulance service. As Physician Advisor for A 5 a da I certify that this ambulance carries the equipment and supplies listed above and meets the'minimum requirements, established by the State of Colorado and Pitkin County, to provide medical care and transportation of the sick and injured at the Advanced Life Support level. Provision of Advanced Life Support is limited as described in 3-CCR-713-6, Section 4 "Medical Acts Allowed EMTs and Paramedics." PF{YSICIA AD R' SIG COLORA[10 MEDICAL LICENSE NUMBER DATE PmmtV COUNTY v VEHICLE SAFETY AND OPERABILITY CERTIFICATION Ambulance Service Name: A3&N Aw t3t.-Kkccf_- License Plate: t 6 Ambulance Number:CIF b i c SYSTEMS ACCEPTABLE NOT ACCEPTABLE COMMENTS Wheels & Tires eering / Alignment Suspension Service Brakes Parking Brake Driving Lights Visual Warning Systems Audible Warning Systems Electrical System t/ �xhaust System t, Fuel System t/ Glass, Mirrors Body& Sheet Metal I, LFE- 14 professing to be a motor vehicle mechanic with training in all of the systems listed above, have evaluated the condition of these systems on the ambulance indicated above and have determined this ambulance to be in safe operating condition. This evaluation does not warrantee the future safety and/or operability of this ambulance due to conditions beyond my control. 1102 3/0/ A CHANIC'S NAME AGENCY/COMPANY PHONE NUMBER DATE I PrrxrN COUNTY BASIC LIFE SUPPORT REQUIRED EQUIPMENT LIST SAFETY EQUIPMENT l/ One 2-1/2 lb. or larger ABC fire extinguisher, accessible from the patient compartment and having been serviced within the last year per NFPA 10 Section 4. �✓ One 5 lb. or larger ABC fire extinguisher, accessible from outside the vehicle and having been serviced within the last year per NFPA 10 Section 4.. l Two "NO SMOKING-OXYGEN IN USE" signs, one in cab and one in patient compartment. Flashlight, 2-D cell equivalent or better with spare bulb and batteries or charger. Set of 3 reflective warning devices. ' One reflective vest, coat or equivalent for each member of the crew normally assigned. 'v At least one "SHARPS" container, clearly labeled and easily accessible in the patient compartment. �—' Restraining devices for all items not in a securable cabinet i EMERGENCY WARNING EQUIPMENT Audible warning device (siren) with at least 2 different tones. L- Visual warning devices (lights) with alternating red and/or blue flashing or rotating visible from all sides simultaneously and clear flashing or oscillating visible from front. I j COMMUNICATIONS EQUIPMENT L'• Mobile VHF radio with appropriate State, Pitkin County and individual agency frequencies. Mobile UHF radio with appropriate State, Pitkin County, hospital and individual agency frequencies. t! Portable radio with charger and/or cellular phone for back-up communications with dispatch and hospitals. 4EDIC'AILFQUIPMENT AND SUPPLIES Airway: t. ." Fixed suction system with wide bore tubing, rigid pharyngeal curved suction tip and soft catheter suction tip with sizes from 5 Fr. to 14 Fr. i. Portable suction system with wide bore tubing, rigid pharyngeal curved suction tip and soft catheter suction tip with sizes from 5 Fr. to 14 Fr. Bulb Syringe. t. Nasopharyngeal airways in pediatric and adult sizes. Oropharyngeal airways in pediatric and adult sizes. -'' Bite stick or equivalent (oropharyngeal airway). �- Fixed oxygen system with a minimum storage capacity of 125 cubic feet (M cylinder) and a minimum delivery capability for three patients simultaneously at flows of at least 1-15 LPM. i- - Portable oxygen system with a minimum storage capacity of 15 cubic feet (D cylinder) and a minimum delivery capability for one patient at flows of at least 1-15 LPM. Infant Bag-Valve-Mask with 500cc bag, reservoir and newborn, infant and child masks. •' Adult Bag-Valve-Mask with 1000cc bag, reservoir and adult mask. 1 "Ali mask attachments must be 15mm'• J L Oxygen masks and cannulas capable of delivering oxygen to adults and infants at flows of at least 1-15 LPM. 1 PITKIN COUNTY BASIC LIFE SUPPORT REQUIRED EQUIPMENT LIST MFDICAT, FOUIPMFNI AND SUPPLIES Diagnostic: L- Blood pressure cuffs in large adult, regular adult, child,infant and neonatal sizes. k-- Stethoscopes in adult and pediatric sizes. ti'Pulse oximeter with adult and pediatric sensors. Immobilization & Splinting: One lower extremity traction splint. L "Upper and lower extremity splints of any type (vacuum, air, SAM, wire, board, etc.). t Long spineboard, vacuum mattress or equivalent with appropriate accessories to immobilize patients from head to heels. u One orthopedic stretcher(scoop). k-�' Short spineboard, KED or equivalent with appropriate straps to immobilize patients from head to pelvis. t Pediatric spineboard or adult spineboard adaptable to pediatric use. t_. Adult and pediatric sized head immobilization equipment for each long spineboard and/or scoop stretcher carried. k Rigid cervical immobilization collars in tall adult through infant sizes. Wound Care: l Bandages, including but not limited to, roller gauze, triangular and elastic per agency needs. 1 Dressings, including but not limited to, trauma, ABD, gauze, occlusive and bandaids per agency needs. l—t Sterile burn sheets. Ir y"Povidone and alcohol swabs or equivalent. Adhesive tape, including but not limited to, 1" and 2" per agency needs. Li Sterile irrigation solution. .ostetncal Supplies: i. Sterile OB kit to include: towels, 4x4s, umbilical tape or cord clamps, scissors, bulb syringe, sterile blanket and sterile gloves. Silver Swaddler and stocking cap or equivalents. Infection Control: Exam gloves in small, medium and large sizes. L,,, Face and eye shields. L ' Fluid-proof gowns with full length sleeves or equivalent. v Disinfectant spray or wipes for personnel and equipment. Miscellaneous: Oral glucose. Activated charcoal. Heavy duty bandage scissors or shears capable of cutting clothing, belts, boots, etc. t- Spill-proof emesis container with at least 1 liter capacity. L- universal or separate male and female urinals. L- Multi-level,wheeled gurney tr' Stair chair or equivalent. Blankets. t Patient compartment heater. 2