Loading...
HomeMy WebLinkAbout2011 Ambulance Licenses NW . �i t� 9 - -±... i 4 4, A 0 ti IN t _ L 1� A PITKIN COUNTY AMBULANCE LICENSE NO. 001 -2011 ASPEN AMBULANCE DISTRICT MEDIC 1 The undersigned, representing the Board of County Commissioners (BOCC) of Pitkin County, Colorado, does 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 below, shall be granted any waivers listed below, and shall be valid for the dates listed below, unless revoked by the BOCC pursuant to the provisions of Title Six (Health and Safety - Ambulance Licensing) of the Pitkin County Code and any other applicable Pitkin County ordinance or law of the State of Colorado. Licensee shall comply with all applicable laws and regulations, including but not limited to Article 3.5 of Title 25, Colorado Revised Statutes, RESTRICTIONS /CONDITIONS: Not Applicable WAIVERS GRANTED: Not Applicable LICENSE VALID FROM: January 1, 2011 through December 31, 2011 BY AUTHORITY OF THE PITKIN COUNTY B e - - D OF COUN ' COMMISSIONERS: December 1, 2010 - '4`H coo //,, f ✓J ���_. e /. SSA ` ,li� l 1: ' c4/ George N: wman, Ch- ir 'y Je 21 e Jones I Board of County Com ' i i, (15 - � - to the Board of County Commissioners . (c Pitkin County Ambulance Service Name Aspen Ambulance District 2011 Service Area: City of Aspen and surrounding Full year X Partial year Emergent _X Transfer Special Event Number of Ambulances Licensed: Six (6) Is this Service Licensed in other Locations? No List Locations: If other than Special Taxing District list Owners with Addresses and Contact Information: Physician Advisor: Dr Chris Martinez Address:_C /O Aspen Valley Hospital, 0401 Castle Creek Rd, Aspen, CO 81611 Strcet/P.O. Box CH) • Slate Zip Contact Information: 970 - 544 - 1314_970 -544 -1590 Voicr Fax E -Mail Colorado Medical License Number: _30993 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 pros ution. Service Director's Signature: Ni$ /I U � /�� One Physician Advisor's Signature ido //tl Date PITKIN COUNTY Application for Ambulance Permit Service Information Service Name Aspen Ambulance District Address:C /O Aspen Valley Hospital, 0401 Castle Creek Rd. Aspen, CO 81611 Street/P.O. City State Zip Communication: 544 -1571 (970) 544 -1578 Moire Fax 1': Mail Vehicle Information Radio Call Sign Medic 1 License Plate 179 -BHG VIN I FDWF37P77EB 1 1957 4x4 Yes (X) No ( ) Year 2007 Make Ford Type F - 350 Where will Vehicle be Stationed Aspen Valley Hospital Waiver Request (Include Reason for Request) A /?� ))/#6 'orrice Dire 's Name Signature Dale (Ambulance Inspector Use Only) Valid Insurance Card Yes ('y No ( ) Valid Registration Card Yes4 No ( ) Inspection Fee 550.00 0 Mechanical Condition Certificate Attached 04 Required BLS Equipment List Attached Required ALS Equipment List Attached N Pass Inspection (yA Fail ( ) Reason for Failure Pitkin County Vehicle Safety and Operability Certification Ambulance Service Aspen Ambulance District Vehicle Radio Call Sign _Medic 1_ System Acceptable Non Acceptable Comment Tires ( ) Wheels ( ( ) Alignment ( ) Suspension s;1, ( ) Brake item ( ) Parking Brake 521 ( ) Headlights (14 ( Stop/Turn/Brake Lts. r ( ) Visual Warning Lights ) ( ) Audible Warning 71 ( ) Electrical System ,T ( ) Exhaust System ( ) Fuel System S 1 ( ) Glass /Mirrors' ( Body & Sheet Metal A ( 1 General Present Condition, Excellent y4 Good ( ) Moderate ( ) Poor ( ) • Mileage when Inspected 7 4 V 7�� I, , professing to be a motor vehicle technician with training in the systems listed above, have evaluated the condition of all systems and have found them to be in a safe and working condition. S j cnature AgencylCrnnpany - �` 1 - ' �-0 7 : 1 rC ' . l O ! Phone Address Ar C i' • 1 1 pat This evaluation will not guarantee future safety and or operability of this ambulance due to conditions beyond the technician's control. Pitkin County Required Basic Life Support Equipment List Inspector &o+} A,r9-vvur Date 11 — a - 1v Vehicle Radio Call Sign ite pd�1 Minimum Equipment Required for Basic Life Support Ambulance Ventilation Equipment (1 Portable suction unit, and a house (fixed system) or backup suction unit, with wide bore tubing, rigid pharyngeal curved suction tip, and soft catheter suction tips to include pediatric sizes 6 fr. through 14 fr. (t4' Bulb syringe. (t V House oxygen with minimum storage capacity of 125 c.f. (M cylinder) and a minimum delivery capability of 2- patients simultaneously through 2 variable flow regulators with capacity at flows of a least 1 -15 L.P.M. V Portable oxygen system with a minimum storage capacity of 15 c.f.. (D cylinder) and a minimum delivery capability for 1- patient at flows of a least 1 -15 L.P.M. (9" Transparent, non - rebreather oxygen masks and nasal cannulas in adult and pediatric sizes. Bag -valve mask resuscitators with oxygen reservoirs and standard 15mm / 21mm fittings in the following sizes; (t Y 500cc bag with transparent masks for infant and neonate. (� 750cc bag with transparent masks for children. � / 1000cc bag with transparent masks for adult. M Nasopharyngeal airways in pediatric and adult sizes 12 fr. through 32 fr. ( Oropharyngeal airways in adult and pediatric sizes to include: infant, child, small adult, adult and large adult. Patient Assessment Equipment (t-K Blood pressure cuffs to include large adult, regular adult, child, infant, and neonatal sizes. (tK Stethoscope in adult and pediatric sizes. (n � Penlight. (t4 Pulse oximeter with adult and pediatric sensors. 2 Splitting Equipment (v)" Lower extremity traction splint. (t,) Upper and lower extremity splints. (V Long board with equipment to immobilize the patient from head to heels. (yam Scoop, vacuum mattress or equivalent, with appropriate accessories to immobilize The patient from head to heels. (4 Short board or equivalent, with the ability to immobilize the patient from head to pelvis. (QV Pediatric immobilization device or adult immobilization device that can be ( A dapted for pediatric use. dult and pediatric cervical spine and head immobilization equipment. Dressing Materials (t.K Bandages - various types and sizes per agency needs and Physician Advisor protocol. (y Multiple dressings (including occlusive dressings), various sizes per ambulance service requirements, needs and Physician Advisor protocol. (t.-) Sterile burn sheets. (0 Alcohol swabs or equivalent. (i4' Adhesive tape, per ambulance service requirements, needs, and Physician Advisor protocol. (V Sterile irrigation solution. Obstetrical Supplies (V Sterile OB kit to include: towels, 4x4 dressings, umbilical tape or cord clamps, scissors, bulb syringe, sterile gloves, and thermal absorbent blanket. (t7 Neonate stocking cap or equivalent. Miscellaneous Equipment Of Heavy bandage scissors, shears or equivalent capable of cutting clothing, belts, boots, etc. (t./ Two working flashlights. V Blankets and appropriate heat source for the ambulance patient compartment. (V Ambulance Service Medical Treatment Protocols. (QY Oral glucose. (t." Spill proofemesis container. ( t)-"Universal and/or separate male / female urinals. q,/ Stair Chair 3 Communications Equipment (4 All communications equipment shall be maintained in good working order. The communications equipment must be capable of transmitting and receiving clear voice communications. Two -way communications that will enable the ambulance personnel to communicate with: (l-f ambulance service's dispatch (' medical control facility or a physician ( receiving facilities Oil mutual aid agencies. Body Substance Isolation Properly Sized To Fit All Personnel To Include; (t Non - sterile disposable gloves in small, medium, and large sizes, to include a minimum 1 box of latex free gloves. (L Protective eyewear. (' Non- sterile surgical masks. (t-r Fluid proof gowns with full- length sleeves or equivalent. (t) Disinfectant spray or wipes for personnel and equipment. (t.) Sharps containers for the appropriate disposal and storage of medical waste and biohazards. (t Y Particulate respirator, N95 type or better. Safety Equipment (1.4 A set of three (3) warning reflectors. ( One (1) ten pound (101b.) or two (2) five pound (5 Ib.) ABC fire extinguishers, with a minimum of one extinguisher accessible from the patient compartment and vehicle exterior and having been serviced within previous year per NFPA 10 section 4. (t. Child safety seat or e ex Appropriate protective restraints for patients, crew, accompanying family members, and other vehicle occupants. (14- secured patient transport system (i.e. wheeled stretcher). (tom Triage tags as approved by the Colorado Department of Public Health and Environment. (tr Restraining devices for all items not in a securable cabinet. V Two "NO SMOKING - OXYGEN IN USE" signs, one in cab, one in patient compartment. (�) Reflective vests, coat or equivalent for each member of the crew normally assigned. Pitkin County Required Advanced Life Support Equipment List Inspector at r Date ll- - Vehicle Radio Call Sign ite- IA 1 Minimum Equipment Requirement for Advanced Life Support Ambulances (yr All Equipment Listed In BLS Equipment list Ventilation Equipment (1.-r Adult and pediatric endotracheal intubation equipment to include stylets and an endotracheal tube stabilization device and endotracheal tubes uncuffed size range from 2.5 - 5.5, and cuffed size range from 6.0 -8.0 per Physician Advisor protocol. (t Laryngoscope and blades, straight, and/or curved of sizes 0-4. (4 Adult and pediatric magill forceps. (6j' End tidal CO2 detector or alternative device, approved by the FDA, for determining correct tube placement. Patient Assessment Equipment (t< Portable, battery operated cardiac monitor- defibrillator with strip chart recorder and adult and pediatric EKG electrodes and defibrillation capabilities. (t-)' Electronic blood glucose measuring device. Intravenous Equipment Or Adult and pediatric intravenous solutions and administration equipment per Physician Advisor protocol. 0) Adult and pediatric intravenous arm boards. Pharmacological Agents (K) Pharmacological agents and delivery devices per Physician Advisor protocol. 40 Pediatric "length based" device for sizing drug dosage calculations and sizing equipment. d As Service Director for 4 Am irk., C e , I certify that this ambulance carries the equipment listed above. This ambulance 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. ./1 ditChCankl-d //d//a Service Director's Name gnature Date lor, p _ k ^' r • c�:zef =fl I Cl ot 1 1 1 L' > .. } � , y., i ,�+y 4- f � �` ill - � '.; PITKIN COUNTY AMBULANCE LICENSE NO. 010 -2011 BASALT AND RURAL FIRE PROTECTION DISTRICT MEDIC 44 The undersigned, representing the Board of County Commissioners (BOCC) of Pitkin County, Colorado, does 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 below, shall be granted any waivers listed below, and shall be valid for the dates listed below, unless revoked by the BOCC pursuant to the provisions of Title Six (Health and Safety - Ambulance Licensing) of the Pitkin County Code and any other applicable Pitkin County ordinance or law of the State of Colorado. Licensee shall comply with all applicable laws and regulations, including but not limited to Article 3.5 of Title 25, Colorado Revised Statutes. RESTRICTIONS /CONDITIONS: Not Applicable WAIVERS GRANTED: Not Applicable LICENSE VALID FROM: January 1, 2011 through December 31, 2011 BY AUTHORITY OF THE PITKIN COU __ r .O' RD OF COU -7. OMMISSIONERS: D: •ember 1, 2010 ee,.H � , ! �; > 0 L AL ." J) • / / , %aim George New an, Ch -ir ' 1 4 r J a 'tt e Jones 1 Board of County Com . sioners r -r1 to the Board of ounty Commissioners pints count' Application for Ambulance Permit Service Information Service Name BaS /4- c..nci Rucwl Fi r& Pro i- e.c-t'wn 7i S Address /° z — CO . t.ir'ly _ Ca rt. or‘ ck & , (U s/ 6 0 1 . 3 Street/P.O. City State Zip Communication Voice Fax E -Man Vehicle Information Radio Call Sign M - t j Lic. Plate C1 3 7 — lA V K Vin# IG133k3y/44Eltn-93y 4X4 Mires No() Year 200'l Make Chfvy Type Chevy 4r'.b.&14e ALS Where will Vehicle will be Stationed 1909 Snown -css Cr_tx./c 2C Sono wnna.ti ri Gf'I Waiver Request (Include Reason for Request) Service Director's Name Signature Date (Ambulance Inspector Use Only) Clear CCIC/NCIC Yes *0 No ( ) Valid Insurance Card Yes (t{ No ( ) Valid Registration Yes (vrNo ( ) Registration Card Yes (t.) ( ) Inspection Fee $50.00 Mechanical Condition Certificate Attached Required BLS Equipment List Attached Required ALS Equipment List Attached{ -5 Pass Inspection Fail ( ) Reason for Failure Sal /b - `L} -201 Inspector's Name Signature Date 1 PITNEY' COUNTY Vehicle Safety and Operability Certification Ambulance SeryiceTBA 4 et A t Niadio Call Sign He o c t { - 4 System Acceptable Non Acceptable Comment Tires X)/ ( 1 Wheels (\EK ( 1 Alignment (�W ( ) Suspension (V V ( ) Brake System ( ( ) Parking Brake C� ( ) Headlights (a ( ) B / Stop)Tumrake Lts. ( ) Visual Warning Lights (NtI ( ) Audible Warning M ( ) Electrical System tr ( ) Exhaust System (t.Y ( ) Fuel System (_�/ ( ) Glass/Mirrors M ( 1 Body & Sheet Metal (") ( ) General Present Condition, Excellent (l600d ( ) Moderate ( ) Poor ( ) Mileage when Inspected 3 0 t at O 1, G Lo -r Z e l ER. , professing to be a motor vehicle technician with training in the systems listed above, have evaluated the condition of all systems and have found them to be in a safe and working condition. V1e.e r Ktelr ov\\C BASsW i- 2\ F Et Signature Agency/Company 7o t}— O07S 1 rA ct 1.0 - Pam_ CAtbn ► \e 816x3 (OiaDitc7. Phone Address Date This evaluation will not guarantee future safety and or operability of this ambulance due to conditions beyond the technician's control. \', hic!: 1. r.,o.r, uo. 1 1 PJ7KJ1, COUNTY Required Basic Life Support Equipment List Inspector Date 10-2 Radio Call Sign 1 1 4 / y Minimum Equipment Required for Basic Life Support Ambulance Ventilation Equipment 1 5.4 , Portable suction unit, and a house (fixed system) or backup suction unit, with wide bore tubing, rigid pharyngeal curved suction tip, and soft catheter suction tips to include pediatric sizes 6 fr. through 14 fr. Bulb syringe House oxygen with minimum storage capacity of 125 c.f. (M cylinder) and a minimum delivery capability of 2- patients simultaneously through 2 variable flow regulators with capacity at flows of a least 1 -15 L.P.M. 10 Portable oxygen system with a minimum storage capacity of 15 c.f.. (D cylinder) and a minimum delivery capability for 1- patient at flows of a least 1 -15 L.P.M. r Transparent, non - rebreather oxygen masks and nasal cannulas in adult and pediatric sizes. Bag -valve mask resuscitators with oxygen reservoirs and standard 15mm / 21 mm fittings in the following sizes; IC) 500cc bag with transparent masks for infant and neonate Ki 750cc bag with transparent masks for children 1000cc bag with transparent masks for adult (Cf Transparent masks for infants, neonate patients, children and adults. j Nasopharyngeal airways in pediatric and adult sizes 12 fr. through 32 fr. \o) Oropharyngeal airways in adult and pediatric sizes to include: infant, child, small adult, adult and large adult. Patient Assessment Equipment td Blood pressure cuffs to include large adult, regular adult, child, infant, and neonatal sizes. (?J Stethoscope in adult and pediatric sizes. Penlight. 0 Pulse oximeter with adult and pediatric sensors. • 2 Splinting Equipment Lower extremity traction splint. fl Upper and lower extremity splints. Long board with approved equipment to immobilize the patient from head to heels 4 °j Scoop, vacuum mattress or equivalent, with appropriate accessories to immobilize The patient from head to heels. ‘ Short board or equivalent, with the ability to immobilize the patient from head to pelvis. t °) Pediatric immobilization devise or adult spine board that can be adapted for pediatric use. 4 Adult and pediatric cervical spine and head immobilization equipment. • Adult and pediatric cervical spine immobilization equipment per Medical Director protocol. Dressing Materials [C, Bandages - various types and sizes per agency needs and Physician Advisor protocol. (4 Multiple dressings (including occlusive dressings), various sizes per ambulance service requirements, needs and Physician Advisor protocol. Sterile bum sheets. Q4 Povidone and alcohol swabs or equivalent. 0 0 Adhesive tape, per ambulance service requirements, needs, and Physician Advisor protocol. r, Sterile irrigation solution. Obstetrical Supplies ta Sterile OB kit to include: towels, 4x4 dressings, umbilical tape or cord clamps, scissors, bulb syringe, sterile gloves, and thermal absorbent blanket. V P Neonate stocking cap or equivalent. Miscellaneous Equipment ( Heavy bandage scissors, shears or equivalent capable of cutting clothing, belts, boots, etc. Two working flashlights. • Blankets and appropriate heat source for the ambulance patient compartment. y Ambulance Service Medical Treatment Protocols • Oral glucose (p Activated charcoal rove - 7' Spill proof emisis container . ... ;.; L. . 3 Universal and/or separate male / female urinals pec Stair Chair Communications Equipment X p All communications equipment shall be maintained in good working order. The communications equipment must be capable of transmitting and receiving clear voice communications. Two -way communications that will enable the ambulance personnel to communicate with: ambulance service's dispatch medical control facility or a physician (..c1 receiving facilities fa mutual aid agencies. Body Substance Isolation Properly Sized To Fit All Personnel To Include; Non - sterile disposable gloves in small, medium, and large sizes, to include a minimum 1 box of latex free gloves. Protective eyewear. D Non - sterile surgical masks. Fluid proof gowns with full - length sleeves or equivalent. Disinfectant spray or wipes for personnel and equipment. Sharps containers for the appropriate disposal and storage of medical waste and biohazards. l�p Particulate respirator, N95 type or better. Safety Equipment i A set of three (3) warning reflectors. W One (1) ten pound (10 Ib.) or two (2) five pound (5 lb.) ABC fire extinguishers, with a minimum of one extinguisher accessible from the patient compartment and vehicle exterior and having been serviced within previous year per NFPA 10 section 4. Child safety seat or equivilant k Appropriate protective restraints for patients, crew, accompanying family members, and other vehicle occupants. f Properly secured patient transport system (Le. wheeled stretcher). Vjzi Triage tags as approved by the Colorado Department of Public Health and Environment. pal Restraining devices for all items not in a securable cabinet. HI 1/4 1, , 4 Two "NO SMOKING - OXYGEN IN USE" signs, one in cab one in patient compartment. Reflective vests, coat or equivalent for each member of the crew normally assigned. BLS Required Equipment MINN COUNTY Required Advanced Life Support Equipment List Inpectort c PAM O ' Radio Call Sign 1 Minimum Equipment Requirement for Advanced Life Support Ambulances } All Equipment Listed In BLS Equipment list Ventilation Equipment r ' Adult and pediatric endotracheal intubation equipment to include stylets and an endotracheal tube stabilization device and endotracheal tubes uncuffed size range from 2.5 — 5.5, and cuffed size range from 6.0 -8.0 per Medical Director protocol. '€ Laryngoscope and blades, straight, and /or curved of sizes 0 -4. 9,, Adult and pediatric magill forceps. " End tidal CO2 detector or alternative device, approved by the FDA, for ( determining correct tube placement. Patient Assessment Equipment 4$ Portable, battery operated cardiac monitor- defibrillator with strip chart recorder and adult and pediatric EKG electrodes and defibrillation capabilities. pcp Electronic blood glucose measuring device. Intravenous Equipment p oi Adult and pediatric intravenous solutions and administration equipment per Physician Advisor protocol. Adult and pediatric intravenous amt boards. Pharmacological Agents Pharmacological agents and delivery devices per Physician Advisor protocol. Pediatric `length based" device for sizing drug dosage calculations and sizing equipment. As Service Director for RAvc. R1 X 1+1/4) % LL j' , I certify that this ambulance carries the equipment listed above. This ambulance 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. k w-'I nlLtt Cot 2-31c Le tiLe 6io P an v o Na e \ Si nature CO Medical Lic. 4 Date • 7110 01,1)667i 10/97/10 Iii... or's me 'Signature Date PHKIN morn" Ambulance Service Name: Snowmass- Wildcat Fire Protection Service Area: Snowmass Village, Wildcat Ranch Full year X Partial year Emergent X Transfer X Special Event X Number of Ambulances Licensed: Three Is this Service Licensed in other Locations? No List Locations: If other than Special Taxing District list Owners with Addresses and Contact Information: Physician Advisor: Dr. Greg Balko Address: PO Box 6534 Snowmass Village. CO 81615 Street/P.O. Box Cit State Zip Contact Information: 970 -922 -6000 same eregbalko @comcast.net Faire Fax E -Mail Colorado Medical License Number: 37036 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 pros: ution. / Service Director's Signature: .., — / _ . / /fret Date 7// r Physician Advisor's Signature / Date RC, T `z W, 444$1, tool ` : ' " ` .: ma y ' —s !},... , .- . C /� �', �T r_0 i { s � 4 a rte +j Y y s ~` 's , tTN � r �n 4 c ti y � r f ` a ir * . t . - 'n PITKIN COUNTY AMBULANCE LICENSE NO. 011 -2011 SNOWMASS - WILDCAT FIRE PROTECTION DISTRICT MEDIC 7 The undersigned, representing the Board of County Commissioners (BOCC) of Pitkin County, Colorado, does hereby grant a license to the above -named applicant to provide ambulance service within Pitkin County. This license shall have upon it any restrictions listed below, shall be granted any waivers listed below, and shall be valid for the dates listed below, unless revoked by the BOCC pursuant to the provisions of Title Six (Health and Safety - Ambulance Licensing) of the Pitkin County Code and any other applicable Pitkin County ordinance or law of the State of Colorado. Licensee shall comply with all applicable laws and regulations, including but not limited to Article 3.5 of Title 25, Colorado Revised Statutes. RESTRICTIONS /CONDITIONS: Not Applicable WAIVERS GRANTED: Not Applicable LICENSE VALID FROM: January 1, 2011 through December 31, 2011 BY AUTHORITY OF THE PITKIN COUNTY B . " D OF COUN OMMISSIONERS: Deg: mber 1, 2010 tic George New an, C ai y `" Je "' e Jones Board of County Comm - sioners �1,, Q , 'to the Board of ounty Commissioners %‘;: is 4 .M 4K .v4$ wnfew.Y ti ¢� ,Na,WY4 LL s✓ w . nns . .p w. '�'' .. i .. ... ` �C ' Applica ion or A u aXermit Service Information Service Name: Snowmass - Wildcat Fire Protection Address: PO Box 6436 Snowmass Village CO $1615 Street/P.O. City State Zip Communication: 970- 923 -2212 970 - 923 -2224 sarthur @swfpd.com Voice Fax E -blait Vehicle Information Radio Call Sign: M7 License Plate: 307 MVT VIN: 1 FDWF37PX5ED 13429 4X4 Yes (X) No ( ) Year: 2005 Make: Ford Type: I Where will Vehicle be Stationed: 5275 Owl Creek Road, Snowmass Village, CO Waiver Request (Include Reason for Request) Steve Sowles /� ervice Director's Name igtiature ' Dale / (Ambulance Inspector Use Onl)) Valid Insurance Card Yes ('j No () Valid Registration Card Yes (4' No ( ) Inspection Fee $50.00 (i Mechanical Condition Certificate Attached ( 4' Required BLS Equipment List Attached ( 4 ' Required ALS Equipment List Attached (4 Pass Inspection (. Fail ( ) Reason for Failure Q lr ; Name Signature � Inspector's Name Date 1 PITIKINCOUNTY Vehicle Safety and Operability Certification Ambulance Service Snowmass- Wildcat Fire Protection District Vehicle Radio Call Sign System Acceptable Non Acceptable Comment Tires ig) ( ) Wheels (Xi1 ( ) Alignment (4) ( ) Suspension 1 1 0 ( ) Brake System ( ) Parking Brake ( ) Headlights (X) ( ) Stop/Turn/Brake Lts. y( ) ( ) Visual Warning Lights G() ( Audible Warning -R) ( ) Electrical System TO ( ) Exhaust System ({A) ( ) Fuel System - 1K) ( ) Glass/Mirrors ( ) Body & Sheet Metal f) ( ) General Present Condition Excellent Good ( ) Moderate ( ) Poor ( ) Mileage when Ins 5 / 01 /`A /K h / , professing to be a motor vehicle technician with training in the systems listed above, have evaluated the condition of all sys s nd ve foun them to be in a safe and working condition. Signature Agency/Company , 76. 9 1 1 -1- / U 37Y50c /QretL 4l: itio(I �o Phone Address Date This evaluation will not guarantee future safety and or operability of this ambulance due to conditions beyond the technician's control. 3 Communications Equipment ( 9" All communications equipment shall be maintained in good working order. The communications equipment must be capable of transmitting and receiving clear voice communications. Two -way communications that will enable the ambulance personnel to communicate with: ( 'j ambulance service's dispatch (4' medical control facility or a physician (5 receiving facilities (•) mutual aid agencies. Body Substance Isolation Properly Sized To Fit All Personnel To Include; (b) Non - sterile disposable gloves in small, medium, and large sizes, to include a minimum 1 box of latex free gloves. ( V Protective eyewear. ({ Non - sterile surgical masks. (4 Fluid proof gowns with full- length sleeves or equivalent. ( v" Disinfectant spray or wipes for personnel and equipment. ('r Sharps containers for the appropriate disposal and storage of medical waste and biohazards. ( rjr Particulate respirator, N95 type or better. Safety Equipment ( vj A set of three (3) warning reflectors. (,i One (1) ten pound (101b.) or two (2) five pound (5 Ib.) ABC fire extinguishers. with a minimum of one extinguisher accessible from the patient compartment and vehicle exterior and having been serviced within previous year per NFPA 10 section 4. (6) Child safety seat or equivalent ( J Appropriate protective restraints for patients, crew, accompanying family members, and other vehicle occupants. (4 Properly secured patient transport system (Le. wheeled stretcher). ( ✓ X Triage tags as approved by the Colorado Department of Public Health and Environment. (X Restraining devices for all items not in a securable cabinet. ( v) Two "NO SMOKING- OXYGEN IN USE" signs, one in cab, one in patient compartment. (v� Reflective vests, coat or equivalent for each member of the crew normally assigned. PITKIN C©UNIVTY Required Advanced Life Support Equipment List Inspector Cis. { /»r Date /170 Vehicle Radio Call Sign iM a Minimum Equipment Requirement for Advanced Life Support Ambulances (4' All Equipment Listed In BLS Equipment list Ventilation Equipment (r) Adult and pediatric endotracheal intubation equipment to include stylets and an endotracheal tube stabilization device and endotracheal tubes uncuffed size range from 2.5 — 5.5, and cuffed size range from 6.0 -8.0 per Physician Advisor protocol. ( < Laryngoscope and blades, straight. and/or curved of sizes 0 -4. (4 Adult and pediatric magill forceps. (1( End tidal CO-, detector or alternative device. approved by the FDA. for determining correct tube placement. Patient Assessment Equipment (J Portable, battery operated cardiac monitor- defibrillator with strip chart recorder and adult and pediatric EKG electrodes and defibrillation capabilities. ( +" Electronic blood glucose measuring device. Intravenous Equipment (I( Adult and pediatric intravenous solutions and administration equipment per Physician Advisor protocol. (4' Adult and pediatric intravenous arm boards. Pharmacological Agents (X Pharmacological agents and delivery devices per Physician Advisor protocol. (4j Pediatric "length based" device for sizing drug dosage calculations and sizing equipment. As Service Director for Snowmass - Wildcat Fire Protection, I certify that this ambulance carries the equipment listed above. This ambulance 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. Steve Sowles �« . :. ftfk/.20r Service Director's Name 'ignatur Date W I - n „ t. s u� - I l'” g t ry -: , Tar... e'-: - -- C vilit �� `` 1 y . r i ' PITKIN COUNTY AMBULANCE LICENSE NO. 012 -2011 SNOWMASS - WILDCAT FIRE PROTECTION DISTRICT MEDIC 8 The undersigned, representing the Board of County Commissioners (BOCC) of Pitkin County, Colorado, does 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 below, shall be granted any waivers listed below, and shall be valid for the dates listed below, unless revoked by the BOCC pursuant to the provisions of Title Six (Health and Safety - Ambulance Licensing) of the Pitkin County Code and any other applicable Pitkin County ordinance or law of the State of Colorado. Licensee shall comply with all applicable laws and regulations, including but not limited to Article 3.5 of Title 25, Colorado Revised Statutes. RESTRICTIONS /CONDITIONS: Not Applicable WAIVERS GRANTED: Not Applicable LICENSE VALID FROM: January 1, 2011 through December 31, 2011 BY AUTHORITY OF THE PITKIN COUN ,, "BOA - D OF C1, N COMMISSIONERS: D ember 1, 2010 = °n / ; q. r George Ne man, Ch: it ' 4 c•Q Je- i e Jones Board of County Com • '•ners %.� § "to the Board o County Commissioners (Ic Application n or A ance ermit Service Information Service Name: Snowmass - Wildcat Fire Protection Address: PO Box 6436 Snowmass Village CO 81615 StreeUF.O. City State Zip Communication: 970- 923 -2212 970 - 923 -2224 sarthur @swfpd.com Voice Fax E-Mail Vehicle Information Radio Call Sign: M8 License Plate: 471 GPI VIN: 1FDWF37F32EA13220 4X4 Yes (X) No ( ) Year: 2002 Make: Ford Type: I Where will Vehicle be Stationed: 5275 Owl Creek Road, Snowmass Village, CO Waiver Request (Include Reason for Request) Steve Sowles j �,� ralslx.l $mice Director's Name e ��� fff Date (Ambulance Inspector Use only) Valid Insurance Card Yes ( No ( ) Valid Registration Card Yes (4 No ( ) Inspection Fee $50.00 (4 1 Mechanical Condition Certificate Attached (4 Required BLS Equipment List Attached (4' Required ALS Equipment List Attached ( ✓) Pass Inspection (✓ Fail ( ) Reason for Failure Inspector's Name V Signature Date 1 FITKINCOUNTY Vehicle Safety and Operability Certification Ambulance Service Sno ass- Wildcat Fire Protection District Vehicle Radio Call Sign �, Svstem Acceptable Non Acceptable Comment Tires I1C) ( 1 Wheels - CO ( ) Alignment ( ) Suspension PC) ( ) Brake System) ( ) Parking Brake ( ) Headlights l ( ) StopiTum/Brake Lts. bC) ( ) Visual Warning Lights 9() ( ) Audible Warning i(1 ( ) Electrical System Oc) ( ) Cr" xhaust System () b4 G Ai a RJa 4,4?/ 6.0. 7vJ Fuel System ( Glass/Mirrors S) ( ) Body & Sheet Metal ( ) General Present Condition Excellent ( ) Good AT Moderate ( ) Poor ( ) Mileage when Inspected y7 / / V 1,3N1,4 041-cit../ / , professing to be a motor vehicle technician with training in the systems listed above, have evaluated the condition of all sys d : e f and them to be in a safe and working condition. 7/1 Signature Agency/r-ompany 7L3 -1 //d 37-0ortaftell h1. 'Wail /o Phone Addras Date This evaluation will not guarantee future safety and or operability of this ambulance due to conditions beyond the technician's control. P177CJN COUNTY / Required Basic Life Support Equipment List Inspector t ro(rr &rJ1au'hi , Date 7/4' 4 Vehicle Radio Call Sign f 1 a Minimum Equipment Required for Basic Life Support Ambulance Ventilation Equipment (4 Portable suction unit, and a house (fixed system) or backup suction unit, with wide bore tubing, rigid pharyngeal curved suction tip, and soft catheter suction tips to include pediatric sizes 6 fr. through 14 fr. ( / Bulb syringe. (✓f House oxygen with minimum storage capacity of 125 c.f. (M cylinder) and a minimum delivery capability of 2- patients simultaneously through 2 variable flow regulators with capacity at flows of a least 1 -15 L.P.M. (/ Portable oxygen system with a minimum storage capacity of 15 c.f.. (D cylinder) and a minimum delivery capability for 1- patient at flows of a least 1 -15 L.P.M. (el Transparent, non- rebreather oxygen masks and nasal cannulas in adult and pediatric sizes. Bag-valve mask resuscitators with oxygen reservoirs and standard 15mm / 21mm fittings in the following sizes; ( 500cc bag with transparent masks for infant and neonate. (� 750cc bag with transparent masks for children. ( ) 1000cc bag with transparent masks for adult. (4' Nasopharyngeal airways in pediatric and adult sizes 12 fr. through 32 fr. ( Oropharyngeal airways in adult and pediatric sizes to include: infant, child. small adult, adult and large adult. Patient Assessment Equipment ( tic Blood pressure cuffs to include large adult, regular adult, child, infant, and neonatal sizes. ( ✓" Stethoscope in adult and pediatric sizes. ( f) Penlight. (e / Pulse oximeter with adult and pediatric sensors. 2 Splinting Equipment (4' Lower extremity traction splint. (O Upper and lower extremity splints. (1 Long board with equipment to immobilize the patient from head to heels. (t/ Scoop, vacuum mattress or equivalent, with appropriate accessories to immobilize The patient from head to heels. (✓J ✓ Short board or equivalent, with the ability to immobilize the patient from head to pelvis. ( Pediatric immobilization device or adult immobilization device that can be adapted for pediatric use. (4 Adult and pediatric cervical spine and head immobilization equipment. Dressing Materials ( Bandages - various types and sizes per agency needs and Physician Advisor protocol. ( J Multiple dressings (including occlusive dressings), various sizes per ambulance service requirements, needs and Physician Advisor protocol. (re Sterile burn sheets. (4 Alcohol swabs or equivalent. ( Adhesive tape, per ambulance service requirements, needs, and Physician Advisor protocol. (4 Sterile irrigation solution. Obstetrical Supplies ( Jj Sterile OB kit to include: towels, 4x4 dressings, umbilical tape or cord clamps, scissors, bulb syringe, sterile gloves, and thermal absorbent blanket. - (4 Neonate stocking cap or equivalent. Miscellaneous Equipment (v, Heavy bandage scissors, shears or equivalent capable of cutting clothing, belts, J boots, etc. (y Two working flashlights. (4 Blankets and appropriate heat source for the ambulance patient compartment. ( Ambulance Service Medical Treatment Protocols. (cc Oral glucose. (I Spill proof emesis container. (ry Universal and/or separate male / female urinals. ( V Stair Chair I;) ..ti Rrrriir(I 1 Li iiu nt 2 3 Communications Equipment (✓f All communications equipment shall be maintained in good working order. The communications equipment must be capable of transmitting and receiving clear voice communications. Two-way communications that will enable the ambulance personnel to communicate with: (4" ambulance service's dispatch ( (j; medical control facility or a physician ( receiving facilities (4 mutual aid agencies. Body Substance Isolation Properly Sized To Fit All Personnel To Include; (,,f Non- sterile disposable gloves in small, medium, and large sizes, to include a minimum I box of latex free gloves. ( Protective eyewear. ( Non - sterile surgical masks. ( Fluid proof gowns with full- length sleeves or equivalent. (vI / Disinfectant spray or wipes for personnel and equipment. (y Sharps containers for the appropriate disposal and storage of medical waste and biohazards. (..)/ Particulate respirator, N95 type or better. Safety Equipment (4" A set of three (3) warning reflectors. (1" One (1) ten pound (10 lb.) or two (2) five pound (5 lb.) ABC fire extinguishers, with a minimum of one extinguisher accessible from the patient compartment and vehicle exterior and having been serviced within previous year per NFPA 10 section 4. (if Child safety seat or equivalent ( +) Appropriate protective restraints for patients, crew, accompanying family members, and other vehicle occupants. (7 Properly secured patient transport system (i.e. wheeled stretcher). (V Triage tags as approved by the Colorado Department of Public Health and Environment. (� Restraining devices for all items not in a securable cabinet. (d Two "NO SMOKING - OXYGEN IN USE" signs, one in cab, one in patient compartment. (✓f Reflective vests, coat or equivalent for each member of the crew normally assigned. PITKIN COUNTY Required Advanced Life Support Equipment List Inspector Cfra Date EtA/ Vehicle Radio Call Sign &' Minimum Equipment Requirement for Advanced Life Support Ambulances ( All Equipment Listed In BLS Equipment list Ventilation Equipment (07 Adult and pediatric endotracheal intubation equipment to include stylcts and an endotracheal tube stabilization device and endotracheal tubes uncuffed size range from 2.5 — 5.5, and cuffed size range from 6.0 -8.0 per Physician Advisor protocol. (v) Laryngoscope and blades, straight, and/or curved of sizes 0 -4. (/ Adult and pediatric magill forceps. ( of End tidal CO, detector or alternative device, approved by the FDA, for determining correct tube placement. Patient Assessment Equipment (ti Portable, battery operated cardiac monitor- defibrillator with strip chart recorder and adult and pediatric EKG electrodes and defibrillation capabilities. (/ Electronic blood glucose measuring device. Intravenous Equipment (v( Adult and pediatric intravenous solutions and administration equipment per Physician Advisor protocol. ( Adult and pediatric intravenous arm boards. Pharmacological Agents ( Pharmacological agents and delivery devices per Physician Advisor protocol., (0 Pediatric `length based" device for sizing drug dosage calculations and sizing equipment. As Service Director for Snowmass - Wildcat Fire Protection. I certify that this ambulance carries the equipment listed above. This ambulance 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. Steve Sowles Service Director's Name Signa ut re Date S IMP, f.; rem et" r y u 1e x+ .` Jt ii .r - _ < i s _ ° `.5 / "^ t � 1 � Y 1 ; -.A ♦. 'l Ferri . t ? _ . �s et.% _1% -) PITKIN COUNTY AMBULANCE LICENSE NO. 013 -2011 SNOWMASS- WILDCAT FIRE PROTECTION DISTRICT MEDIC 9 The undersigned, representing the Board of County Commissioners (BOCC) of Pitkin County, Colorado, does 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 below, shall be granted any waivers listed below, and shall be valid for the dates listed below, unless revoked by the BOCC pursuant to the provisions of Title Six (Health and Safety - Ambulance Licensing) of the Pitkin County Code and any other applicable Pitkin County ordinance or law of the State of Colorado. Licensee shall comply with all applicable laws and regulations, including but not limited to Article 3.5 of Title 25, Colorado Revised Statutes. RESTRICTIONS /CONDITIONS: Not Applicable WAIVERS GRANTED: Not Applicable LICENSE VALID FROM: January 1, 2011 through December 31, 2011 BY AUTHORITY OF THE PITKIN COUNTY BO • - D OF COUN . OMMISSIONERS: D >.ember 1, 2010 ..� r ,Nr�, ,, • 1 . .. i' c a� i. J ..i.: \ i� /41„Q✓ George New an, C -ir f,t " AL . - : ` e;'e Jones / Board of County Com sioner : `e. " rk ,. the Board of County Commissioners v Cc Appli o� A mb u a ermit Service Information Service Name: Snowmass- Wildcat Fire Protection Address: PO Box 6436 Snowmass Vi11aze CO 81615 Strect/P.O, City State Zip Communication: 970- 923 -2212 970 -923 -2224 sarthur @swfpd.com Voice Fax E-Mail Vehicle Information Radio Call Sign: M9 License Plate: Unavailable VIN: 1FDAF4HR3AEB39794 4X4 Yes (X) No ( ) Year: 2010 Make: Ford Type: I Where will Vehicle be Stationed: 5275 Owl Creek Road. Snowmass Village, CO Waiver Request (Include Reason for Request) i Steve Sowles ( / Scrsire Director's Name Stgnatu ( ` //47.20( e � (Ambulance Inspector Use Only) Valid Insurance Card Yes (1 No ( ) Valid Registration Card Yes (d) No ( ) Inspection Fee $50.00 (if Mechanical C edition Certificate Attached elf Required BLS Equipment List Attached (1 Required ALS Equipment List Attached ( Pass Inspection (64 Fail ( ) Reason for Failure .F l (1w,/4y5 / a a Inspector's Name 'gnaw Date / 'gna 1 PITKIIV COUNTY Vehicle Safety and Operability Certification Ambulance Service Snowmass- Wildcat Fire Protection District Vehicle Radio Call Sign 1/U&J,1t 9 System Acceptable Non Acceptable Comment Tires 0 ( ) Wheels 60 ( ) Alignment 90 ( ) Suspension 64 ( ) Brake System P ( ) Parking Brake () ( ) Headlights on ( ) Stop/Turn/Brake Lts. 00 ( ) Visual Warning Lights eC) ( ) Audible Warning PQ ( 1 Electrical System Ik't ( 1 Exhaust System M) ( 1 Fuel System W ( ) Glass/Mirrors Y) ( 1 Body & Sheet Metal N ( ) General Present Condition /, / Excellent) Good ( ) Moderate ( ) Poor ( ) Mileage when Inspected W. 6-t 0 1, BN ‘ G 11 sk Ji _// , professing to be a motor vehicle technician wi . training in the systems listed above, have evaluated the condition of all sy • • ave fo, d th to be in a safe and working condition. , (7 --br Signature Agency/Company 99e- fi3 S /ro 3 7yf Oki/ On/ W. IAbi/ /o Phone Address Date This evaluation will not guarantee future safety and or operability of this ambulance due to conditions beyond the technician's control. . 1 PITKIN COUNTY Required Basic Life Support Equipment List Inspector :� , /c -( /?Ct ,l.f Date 1 // /4 Vehicle Radio Call Sign Minimum Equipment Required for Basic Life Support Ambulance Ventilation Equipment (✓ Portable suction unit, and a house (fixed system) or backup suction unit, with wide bore tubing, rigid pharyngeal curved suction tip, and soft catheter suction tips to include pediatric sizes 6 fr. through 14 fr. (4 Bulb syringe. (4 House oxygen with minimum storage capacity of 125 c.f. (M cylinder) and a minimum delivery capability of 2- patients simultaneously through 2 variable flow regulators with capacity at flows of a least 1 -15 L.P.M. (/) Portable oxygen system with a minimum storage capacity of 15 c.f.. (1) cylinder) and a minimum delivery capability for 1- patient at flows of a least 1-15 L.P.M. (4 Transparent, non - rebreather oxygen masks and nasal cannulas in adult and pediatric sizes_ Bag -valve mask resuscitators with oxygen reservoirs and standard 15mm / 21 mm fittings in the following sizes: (4 500cc bag with transparent masks for infant and neonate. (+� 750cc bag with transparent masks for children. (t4 1000cc bag with transparent masks for adult. (,4 Nasopharyngeal airways in pediatric and adult sizes 12 fr. through 32 fr. (4' Oropharyngeal airways in adult and pediatric sizes to include: infant, child, small adult, adult and large adult. Patient Assessment Equipment (4} Blood pressure cuffs to include large adult. regular adult. child. infant, and / neonatal sizes. (4 Stethoscope in adult and pediatric sizes. (4 Penlight. (✓r Pulse oximeter with adult and pediatric sensors. 2 Splinting Equipment ( Lower extremity traction splint. (� Upper and lower extremity splints. (4' Long board with equipment to immobilize the patient from head to heels. (I Scoop, vacuum mattress or equivalent, with appropriate accessories to immobilize The patient from head to heels. (4 Short board or equivalent, with the ability to immobilize the patient from head to pelvis. (i4 Pediatric immobilization device or adult immobilization device that can be adapted for pediatric use. (r) Adult and pediatric cervical spine and head immobilization equipment. Dressing Materials (4' Bandages - various types and sizes per agency needs and Physician Advisor protocol. (4 Multiple dressings (including occlusive dressings), various sizes per ambulance service requirements, needs and Physician Advisor protocol. (r) Sterile burn sheets. (vc Alcohol swabs or equivalent. ( Adhesive tape, per ambulance service requirements, needs, and Physician Advisor protocol. (ry Sterile irrigation solution. Obstetrical Supplies (4' Sterile OB kit to include: towels, 4x4 dressings, umbilical tape or cord clamps, scissors, bulb syringe, sterile gloves, and thermal absorbent blanket. („)/ Neonate stocking cap or equivalent. Miscellaneous Equipment (/ Heavy bandage scissors, shears or equivalent capable of cutting clothing, belts, boots, etc. (vi Two working flashlights. (.)" Blankets and appropriate heat source for the ambulance patient compartment. (4' Ambulance Service Medical Treatment Protocols. (v/ Oral glucose. ( i( Spill proof emesis container. V Universal and/or separate male / female urinals. (4 Stair Chair I.,�ni�nrr • 3 Communications Equipment ( 3' All communications equipment shall be maintained in good working order. The communications equipment must be capable of transmitting and receiving clear voice communications. Two -way communications that will enable the ambulance personnel to communicate with: ('' ambulance service's dispatch (. medical control facility or a physician 0 receiving facilities ( mutual aid agencies. Body Substance Isolation Properly Sized To Fit All Personnel To Include; ( Non - sterile disposable gloves in small, medium, and large sizes, to include a minimum 1 box of latex free gloves. ( el Protective eyewear. (.1 Non - sterile surgical masks. ())' Fluid proof gowns with full - length sleeves or equivalent. ('r Disinfectant spray or wipes for personnel and equipment. (r.) Sharps containers for the appropriate disposal and storage of medical waste and biohazards. (4 Particulate respirator, N95 type or better. Safety Equipment (c4 A set of three (3) waming reflectors. (J One (I) ten pound (101b.) or two (2) five pound (51b.) ABC fire extinguishers, with a minimum of one extinguisher accessible from the patient compartment and vehicle exterior and having been serviced within previous year per NFPA 10 section 4. (4' Child safety seat or equivalent ( $ Appropriate protective restraints for patients, crew, accompanying family ` members, and other vehicle occupants. (i Properly secured patient transport system (i.e. wheeled stretcher). (4' Triage tags as approved by the Colorado Department of Public Health and Environment. (J' Restraining devices for all items not in a securable cabinet. (� Two "NO SMOKING- OXYGEN IN USE" signs, one in cab, one in patient - compartment. (7 Reflective vests, coat or equivalent for each member of the crew normally assigned. PITKIN COUVTY Required Advanced Life Support Equipment List Inspector CtnJ daft _ Date 0/4 "o Vehicle Radio Call Sign W\ �t Minimum Equipment Requirement for Advanced Life Support Ambulances (✓ All Equipment Listed In BLS Equipment list Ventilation Equipment (1 Adult and pediatric endotracheal intubation equipment to include stylets and an endotracheal tube stabilization device and endotracheal tubes uncuffed size range from 2.5 — 5.5. and cuffed size range from 6.0 -8.0 per Physician Advisor protocol. (Jr Laryngoscope and blades, straight, and /or curved of sizes 0-4. (J' Adult and pediatric magill forceps. (4 End tidal 002 detector or alternative device, approved by the FDA. for determining correct tube placement. Patient Assessment Equipment (vc Portable, battery operated cardiac monitor- defibrillator with strip chart recorder and adult and pediatric EKG electrodes and defibrillation capabilities. ( Electronic blood glucose measuring device. Intravenous Equipment V Adult and pediatric intravenous solutions and administration equipment per Physician Advisor protocol. (v Adult and pediatric intravenous arm boards. Pharmacological Agents (4 Pharmacological agents and delivery devices per Physician Advisor protocol. (d Pediatric "length based" device for sizing drug dosage calculations and sizing equipment. As Service Director for Snowmass - Wildcat Fire Protection, t certify that this ambulance carries the equipment listed above. This ambulance 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. Steve Sowies a � rrl8 °ro Service Director's Name Siena re 111 Date c 7 ,,,n‘..... y _. S e lag C Ot Al' Y ` 7r z"' . T v PITKIN COUNTY AMBULANCE LICENSE NO. 002 -2011 ASPEN AMBULANCE DISTRICT MEDIC 2 The undersigned, representing the Board of County Commissioners (BOCC) of Pitkin County, Colorado, does 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 below, shall be granted any waivers listed below, and shall be valid for the dates listed below, unless revoked by the BOCC pursuant to the provisions of Title Six (Health and Safety - Ambulance Licensing) of the Pitkin County Code and any other applicable Pitkin County ordinance or law of the State of Colorado. Licensee shall comply with all applicable laws and regulations, including but not limited to Article 3.5 of Title 25, Colorado Revised Statutes. RESTRICTIONS /CONDITIONS: Not Applicable WAIVERS GRANTED: Not Applicable LICENSE VALID FROM January 1, 2011 through December 31, 2011 BY AUTHORITY OF THE PITKIN COUNTY : • s RD OF COU COMMISSIONERS: December 1, 2010 , „ r ` " ... fia n f .4V 2.4S 'r ' A . I{! at George Ne man, ( hair {' J ,ette Jones Board of County Co . issioners i , - -• 6 I 'j to the Board • County Commissioners (c PITKIN COUNTY Application for Ambulance Permit Service Information Service Name Aspen Ambulance District Address:C /O Aspen Valley Hospital, 0401 Castle Creek Rd. Aspen, CO 81611 Street/P.O. City State Zip Communication: (970) 544 -1571 (970) 544 -1578 Voice Fax E -Mail Vehicle Information Radio Call Sign Medic 2 License Plate 084 - BFC VIN 1FDWF37F42EB84123 4X4 Yes (X) No ( ) Year 2002 Make Ford Type F -350 Where will Vehicle be Stationed Aspen Valley Hospital Waiver Request (Include Reason for Request) C1vk1 1611° ,Service 01 is Name Signature Date (Ambulance Inspector Use Only) Valid Insurance Card Yes Q No ( ) Valid Registration Card Yes in No ( ) Inspection Fee $50.00 pC) Mechanical Condition Certificate Attached p'4- Required BLS Equipment List Attached1A) Required ALS Equipment List Attached (xI Pass Inspection (➢Q Fail ( ) Reason for Failure a -to 1 Pit&in County Vehicle Safety and Operability Certification Ambulance Service Aspen Ambulance District Vehicle Radio Call Sign Medic 2__ System Acceptable Non Acceptable Comment Tires ( ) Wheels ( ) Alignment ( ) Suspension ( ) Brake System > ( ) Parking Brake iiiir ( ) Headlights ( ) StopiTurn/Brake Lts. ( ) Visual Warning Light ( ) Audible Warning .�,(`' ( ) Electrical System `'ll' ( ) Exhaust System 4 ( ) Fuel System ( ) GlassIMirrors 4 () Body & Sheet Metal C ( General Present Condition, Excelled V Good ( Moderate ( Poor ( ) Mileage when Inspected ,Tt { ' 7 i, A/' 0"' \ -Q C _ , professing to be a motor vehicle technician with training in the systems listed above, have evaluated the condition of all systems and have found them to be in a safe and working condition. I / _ a) atur Agenc ;VCompa ' . Jar I. A - 1 "1 7 Jo t • y. „G'1z-' - 10 • us — Photte Address Co Co tlGR D to This evaluation will not guarantee future safety and or operability of this ambulance due to conditions beyond the technician's control. Pitkin County Required Basic Life Support Equipment List Inspector Sc if AN \w Date 1 1 — ip Vehicle Radio Call Sign t'1 Minimum Equipment Required for Basic Life Support Ambulance Ventilation Equipment (1..) Portable suction unit, and a house (fixed system) or backup suction unit, with wide bore tubing, rigid pharyngeal curved suction tip, and soft catheter suction tips to include pediatric sizes 6 fr. through 14 fr. (V Bulb syringe. (1.7 House oxygen with minimum storage capacity of 125 c.f. (M cylinder) and a minimum delivery capability of 2- patients simultaneously through 2 variable flow regulators with capacity at flows of a least 1 -15 L.P.M. NV Portable oxygen system with a minimum storage capacity of 15 c.f.. (D cylinder) and a minimum delivery capability for 1- patient at flows of a least 1 -15 L.P.M. (V Transparent, non- rebreather oxygen masks and nasal cannulas in adult and pediatric sizes. Bag -valve mask resuscitators with oxygen reservoirs and standard 15mm / 21mm fittings in the following sizes; (t� 500cc bag with transparent masks for infant and neonate. (t.)' 750cc bag with transparent masks for children. (t.>' 1000cc bag with transparent masks for adult. (� Nasopharyngeal airways in pediatric and adult sizes 12 fr. through 32 fr. (1-) Oropharyngeal airways in adult and pediatric sizes to include: infant, child, small adult, adult and large adult. Patient Assessment Equipment (.Blood pressure cuffs to include large adult, regular adult, child, infant, and neonatal sizes. (4 / Stethoscope in adult and pediatric sizes. ( t.{ Penlight. (1.'Pulse oximeter with adult and pediatric sensors. 2 Splinting Equipment (V Lower extremity traction splint. (Lj" and lower extremity splints. (L Long board with equipment to immobilize the patient from head to heels. (1" Scoop, vacuum mattress or equivalent, with appropriate accessories to immobilize The patient from head to heels. (‘./ Short board or equivalent, with the ability to immobilize the patient from head to pelvis. (V Pediatric immobilization device or adult immobilization device that can be Adapted for pediatric use. tv) Adult and pediatric cervical spine and head immobilization equipment. Dressing Alaterials (t Bandages - various types and sizes per agency needs and Physician Advisor protocol. (+1 Multiple dressings (including occlusive dressings), various sizes per ambulance service requirements, needs and Physician Advisor protocol. (+r Sterile burn sheets. (Ai)' Alcohol swabs or equivalent. (t Adhesive tape, per ambulance service requirements, needs, and Physician Advisor protocol. V Sterile irrigation solution. Obstetrical Supplies (c)./ Sterile OB kit to include: towels, 4x4 dressings, umbilical tape or cord clamps, scissors, bulb syringe, sterile gloves, and thermal absorbent blanket. (IV Neonate stocking cap or equivalent. Miscellaneous Equipment (14 Heavy bandage scissors, shears or equivalent capable of cutting clothing, belts, boas, etc. (la Two working flashlights. (yam Blankets and appropriate heat source for the ambulance patient compartment. (Lr Ambulance Service Medical Treatment Protocols. cur' Oral glucose. (4" Spill proofemesis container. vcrsal and/or separate male / female urinals. Stair Chair 3 Communications Equipment (" All communications equipment shall be maintained in good working order. The communications equipment must be capable of transmitting and receiving clear voice communications. Two -way communications that will enable the ambulance personnel to communicate with: (LK ambulance service's dispatch (L medical control facility or a physician (14j receiving facilities (tX mutual aid agencies. Body Substance Isolation Properly Sized To Fit All Personnel To Include; (frr Non- sterile disposable gloves in small, medium, and large sizes, to include a minimum 1 box of latex free gloves. ( c). Protective eyewear. ( t.K Non - sterile surgical masks. ( t)/ Fluid proof gowns with full - length sleeves or equivalent. 61.)--- spray or wipes for personnel and equipment. (t Sharps containers for the appropriate disposal and storage of medical waste and biohazards. (Or Particulate respirator, N95 type or better. Safety Equipment ( . A set of three (3) warning reflectors. (V One (1) ten pound (101b.) or two (2) five pound (5 lb.) ABC fire extinguishers, with a minimum of one extinguisher accessible from the patient compartment and vehicle exterior and having been serviced within previous year per NFPA 10 section 4. (['Child safety seat or equivalent ([Appropriate protective restraints for patients, crew, accompanying family members, and other vehicle occupants. (c.) Properly secured patient transport system (i.e. wheeled stretcher). (X Triage tags as approved by the Colorado Department of Public Health and Environment. ( <Rcstraining devices for all items not in a securable cabinet. ( — T w o "NO SMOKING - OXYGEN IN USE" signs, one in cab, one in patient compartment. (121 Reflective vests, coat or equivalent for each member of the crew normally assigned. Pitkin County Required Advanced Life Support Equipment List Inspector 5t rot - x' Date I I -"D - U) Vehicle Radio Call Sign IV\ - Minimum Equipment Requirement for Advanced Life Support Ambulances (L All Equipment Listed In BLS Equipment list Ventilation Equipment (9 Adult and pediatric endotracheal incubation equipment to include stylets and an endotracheal tube stabilization device and endotracheal tubes uncuffed size range from 2.5 — 5.5, and cuffed size range from 6.0-8.0 per Physician Advisor protocol. (i Laryngoscope and blades, straight, and/or curved of sizes 0-4. (ty Adult and pediatric magill forceps. 4,4/ End tidal CO2 detector or altemative device, approved by the FDA, for determining correct tube placement. Patient Assessment Equipment (L Portable, battery operated cardiac monitor- defibrillator with strip chart recorder and adult and pediatric EKG electrodes and defibrillation capabilities. (t4/ Electronic blood glucose measuring device. Intravenous Equipment NV Adult and pediatric intravenous solutions and administration equipment per Physician Advisor protocol. (� Adult and pediatric intravenous arm boards. Ph armacological Agents (14" Pharmacological agents and delivery devices per Physician Advisor protocol. 04 Pediatric `length based" device for sizing drug dosage calculations and sizing equipment. As Service Director for t15 tce , I certify that this ambulance carries the equipment listed above. This ambulance 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. dim Mc4c-tdsd-i P /1/3 /10 Service Director's Name S' ature Date w T ` ti ,- e-" 2, j frJik4i _ . 7 Y Y r C l # 1J \ 1 t r " , : J " r "' r ti R " ; .e ,- PITKIN COUNTY AMBULANCE LICENSE NO. 003 -2011 ASPEN AMBULANCE DISTRICT MEDIC 3 The undersigned, representing the Board of County Commissioners (BOCC) of Pitkin County, Colorado, does 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 below, shall be granted any waivers listed below, and shall be valid for the dates listed below, unless revoked by the BOCC pursuant to the provisions of Title Six (Health and Safety - Ambulance Licensing) of the Pitkin County Code and any other applicable Pitkin County ordinance or law of the State of Colorado. Licensee shall comply with all applicable laws and regulations, including but not limited to Article 3.5 of Title 25, Colorado Revised Statutes. RESTRICTIONS /CONDITIONS: Not Applicable WAIVERS GRANTED: Not Applicable LICENSE VALID FROM: January 1, 2011 through December 31, 2011 BY AUTHORITY OF THE PITKIN COUNTY : • • ' D OF COU COMMISSIONERS: - cember 1, 2010 C !�9/ LL i(/ George Ne , man, hair j 0 I Jea X tte Jones Board of County C. missioners; * "° r Cle <to the Board • County Commissioners if, o PITKIN COUNTY Application for Ambulance Permit Service Information Service Name Aspen Ambulance District Address:C /O Aspen Valley Hospital, 0401 Castle Creek Rd. Aspen, CO 81611 Street/P.O. City Stale Zip Communication: (970) 544 -1571 (970) 544 -1578 Voice Fax E -Mail Vehicle Information Radio Call Sign Medic 3 License Plate 025 -A31 VIN 4X4 Yes (X) No ( ) Year 2010 Make GMC Type AM Where will Vehicle be Stationed Aspen Valley Hospital Waiver Request (Include Reason for Request) tip/ V t) ti�1�1 t Service Direr sName Signature Date (Ambulance Inspector Use Only) Valid Ins nce Card Yes 69 No ( ) Valid Registration Card Yes 09 No ( ) Inspection Fee 550.00 QQ Mechanical Condition Certificate Attached' Required BLS Equipment List Attached (y1 Required ALS Equipment List Attached NT Pass Inspection tfi Fail ( ) Reason for Failure i Pe la 1 Pitkin County Vehicle Safety and Operability Certification Ambulance Service Aspen Ambulance District Vehicle Radio Call Sign _ Medic 3_ System Acceptable Non Acceptable Comment Tires 96 ( ) Wheels (>4 ( ) Alignment (• ( ) Suspension 95 ( ) Brake System ( ( Parking Brake (4 ( ) Headlights ('4 ( ) Stop/Turn/Brake Lts. (M' ( ) Visual Warning Lights pa ( ) Audible Warning 9d ( ) Electrical System ( ( ) Exhaust System Q� ( ) Fuel System ( ( ) Glass/Mirrors (f ( Body & Sheet Metal 9 ( ) General Present Condition, Excellent (4 Good ( ) Moderate ( ) Poor ( ) Mileage when Inspected )O 1, Alph rq' ( 4 , professing to be a motor vehicle technician with training in the systems listed above, have evaluated the condition of all systems and have found them to be in a safe and working condition. , g447 /1-0.....et PfM t � r Signature Agency /Company 9 i5 i7 IF 9-0 Phase Address Date This evaluation will not guarantee future safety and or operability of this ambulance due to conditions beyond the technician's control. \' irfui IL. I nsjx ci � n 1 Pitkin County Required Basic Life Support Equipment List Inspector Sc o' i A4r-+ \ U r Date I l' P Vehicle Radio Call Sign M Minimum Equipment Required for Basic Life Support Ambulance Ventilation Equipment ( ) Portable suction unit, and a house (fixed system) or backup suction unit, with wide bore tubing, rigid pharyngeal curved suction tip, and soft catheter suction tips to include pediatric sizes 6 fr. through 14 fr. (Lc Bulb syringe. (y' House oxygen with minimum storage capacity of 125 c.f. (M cylinder) and a minimum delivery capability of 2- patients simultaneously through 2 variable flow regulators with capacity at flows of a least 1 -15 L.P.M. (1.Y Portable oxygen system with a minimum storage capacity of 15 c.f.. (D cylinder) and a minimum delivery capability for 1- patient at flows of a least 1 -15 L.P.M. (t- Transparent, non - rebreather oxygen masks and nasal cannulas in adult and pediatric sizes. Bag -valve mask resuscitators with oxygen reservoirs and standard 15mm / 21mm fittings in the following sizes; frr 500cc bag with transparent masks for infant and neonate. (y' 750cc bag with transparent masks for children. (v)' 1000cc bag with transparent masks for adult. Nasopharyngeal airways in pediatric and adult sizes 12 fr. through 32 fr. (1y Oropharyngeal airways in adult and pediatric sizes to include: infant, child, small adult, adult and large adult. Patient Assessment Equipment ( ) Blood pressure cuffs to include large adult, regular adult, child, infant, and neonatal sizes. G-K Stethoscope in adult and pediatric sizes. 0. Penlight. (1 K Pulse oximeter with adult and pediatric sensors. 2 Splinting Equipment (L Lower extremity traction splint. ( ) Upper and lower extremity splints. (.y Long board with equipment to immobilize the patient from head to heels. (y Scoop, vacuum mattress or equivalent, with appropriate accessories to immobilize The patient from head to heels. (9y Short board or equivalent, with the ability to immobilize the patient from head to pelvis. ( ) Pediatric immobilization device or adult immobilization device that can be Adapted for pediatric use. (ur Adult and pediatric cervical spine and head immobilization equipment. Dressing Materials kr Bandages - various types and sizes per agency needs and Physician Advisor protocol. (_),' Multiple dressings (including occlusive dressings), various sizes per ambulance service requirements, needs and Physician Advisor protocol. (kr Sterile burn sheets. (9" Alcohol swabs or equivalent. (L.-Y Adhesive tape, per ambulance service requirements, needs, and Physician Advisor protocol. Pr Sterile irrigation solution. Obstetrical Supplies (t> Sterile OB kit to include: towels, 4x4 dressings, umbilical tape or cord clamps, scissors, bulb syringe, sterile gloves, and thermal absorbent blanket. (er Neonate stocking cap or equivalent. Miscellaneous Equipment (L K Heavy bandage scissors, shears or equivalent capable of cutting clothing, belts, boots, etc. Two working flashlights. (t Y Blankets and appropriate heat source for the ambulance patient compartment. (yam Ambulance Service Medical Treatment Protocols. (t4 Oral glucose. (tip Spill proof emesis container. (Er Universal and/or separate male / female urinals. (LK Stair Chair 3 Communications Equipment All communications equipment shall be maintained in good working order. The communications equipment must be capable of transmitting and receiving clear voice communications. Two -way communications that will enable the ambulance personnel to communicate with: ambulance service's dispatch (vr medical control facility or a physician (Lr receiving facilities (9 mutual aid agencies. Body Substance Isolation Properly Sized To Fit All Personnel To Include; (b Non - sterile disposable gloves in small, medium, and large sizes, to include a minimum 1 box of latex free gloves. (t4 Protective eyewear. (ta/ Non- sterile surgical masks. (L Fluid proof gowns with full - length sleeves or equivalent. (1-- Disinfectant spray or wipes for personnel and equipment. (y Sharps containers for the appropriate disposal and storage of medical waste and biohazards. (Ly" Particulate respirator, N95 type or better. Safety Equipment A set of three (3) warning reflectors. (1-).- (1) ten pound (10 Ib.) or two (2) five pound (5 Ib.) ABC fire extinguishers, with a minimum of one extinguisher accessible from the patient compartment and vehicle exterior and having been serviced within previous year per NFPA 10 section 4. (t) Child safety seat or equivalent (t.)— Appropriate protective restraints for patients, crew, accompanying family members, and other vehicle occupants. (yam Properly secured patient transport system (i.e. wheeled stretcher). Triage tags as approved by the Colorado Department of Public Health and Environment. (i4 Restraining devices for all items not in a securable cabinet. — () Two "NO SMOKING - OXYGEN IN USE" signs, one in cab, one in patient compartment. (t< Reflective vests, coat or equivalent for each member of the crew normally assigned. , - Pitlrin County Required Advanced Life Support Equipment List Inspector 5e.e+l ht Date ( t -3 -1 Vehicle Radio Call Sign M 3 Minimum Equipment Requirement for Advanced Life Support Ambulances (vJ All Equipment Listed In BLS Equipment list Ventilation Equipment (y Adult and pediatric endotracheal intubation equipment to include stylets and an endotracheal tube stabilization device and endotracheal tubes uncuffed size range from 2.5 - 5.5, and cuffed size range from 6.0 -8.0 per Physician Advisor protocol. e -r Laryngoscope and blades, straight, and/or curved of sizes 0-4. (i3- Adult and pediatric magill forceps. (tom End tidal CO2 detector or alternative device, approved by the FDA, for determining correct tube placement. Patient Assessment Equipment � � pek:04— ( Portable, battery operated cardiac monitor- defibrillator with strip chart recorder and adult and pediatric EKG electrodes and defibrillation capabilities. (t� Electronic blood glucose measuring device. Intravenous Equipment (t) Adult and pediatric intravenous solutions and administration equipment per Physician Advisor protocol. ( yam Adult and pediatric intravenous arm boards. Pharmacological Agents (LK Pharmacological agents and delivery devices per Physician Advisor protocol. (� Pediatric "length based" device for sizing drug dosage calculations and sizing equipment. As Service Director for s Fyn (sp^�ce , I certify that this ambulance carries the equip ent listed above. This ambulance 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. 4;c6,.,,tww✓ C / ///340 Service Director's Name Sign ure Date r, �.• ' !` W S.4 _ 4 _ a j� Thdl ;.,."' i' , j= - , Vii. C O II 1T t` r do ...., to • PITKIN COUNTY AMBULANCE LICENSE NO. 004 -2011 ASPEN AMBULANCE DISTRICT MEDIC 4 The undersigned, representing the Board of County Commissioners (BOCC) of Pitkin County, Colorado, does 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 below, shall be granted any waivers listed below, and shall be valid for the dates listed below, unless revoked by the BOCC pursuant to the provisions of Title Six (Health and Safety - Ambulance Licensing) of the Pitkin County Code and any other applicable Pitkin County ordinance or law of the State of Colorado. Licensee shall comply with all applicable laws and regulations, including but not limited to Article 3.5 of Title 25, Colorado Revised Statutes. RESTRICTIONS /CONDITIONS: Not Applicable WAIVERS GRANTED: Not Applicable LICENSE VALID FROM: January 1, 2011 through December 31, 2011 BY AUTHORITY OF THE PITKIN C¢IJ t = - • - D OF COU COMMISSIONERS: ember 1, 2010 —oN. ' ' '4 "I R' p, st. SEAL . ,e ' dog George Ne an, C air '4, , ` mo d : n -tte Jones Board of County Co , issioners ler • to the Board o County Commissioners • PITKIN COUNTY Application for Ambulance Permit Service Information Service Name Aspen Ambulance District Address:C /O Aspen Valley Hospital, 0401 Castle Creek Rd. Aspen, CO 81611 Street/P.O. City State Zip Communication: (970) 544 -1571 (970) 544 -1578 Voice Fax E -Mail Vehicle Information Radio Call Sign Medic 4 License Plate 523AVN VIN 1 GBJK34F7WF036115 4X4 Yes (X) No ( ) Year 1998 Make Chevy Type AM Where will Vehicle be Stationed Aspen Valley Hospital Waiver Request (include Reason for Request) / /b� /o Se Director's Name Signature Dale (Ambulance Inspector Use Only) Valid Insurance Card Yes (Q No ( ) Valid Registration Card Yes ?' No ( ) Inspection Fee 550.00 0 Mechanical Condition Certificate Attached Required BLS Equipment List Attached N. Required ALS Equipment List Attached Pass Inspectiony) Fail ( ) Reason for Failure 1 Pitkin County Vehicle Safety and Operability Certification Ambulance Service Aspen Ambulance District Vehicle Radio Call Sign _ Medic 4 System Acceptable Non Acceptable Comment Tires P6 ( ) Wheels ( ) Alignment ( ( ) Suspension ) Brake System (r ( ) Parking Brake (.1 ( ) Headlights ( ( Stop/Turn/Brake Lts. (X ( ) Visual Warning Lights (A) ( ) Audible Warning () Electrical System (k ( ) Exhaust System 21 ( 1 Fuel System ()1 ( ) Glass/Mirrors ( ) Body & Sheet Metal yr) ( ) General Present Condition, y Excellent ( ) Good ( ) Moderate j>� Poor ( ) n , / Mileage when Inspected �1 (' 0 `' ' Q.ki era i professing to be a motor vehicle technici with training in the systems listed above, have evaluated the condition of all syst - . and have fo d them to be in a safe and working condition. p - Y2 Gene Signature Agency/ P y? l/ l l7/ Phone Address Date This evaluation will not guarantee future safety and or operability of this ambulance due to conditions beyond the technician's control. Vrhicl. 1 )specti,m 1 Pitkin County Required Basic Life Support Equipment List Inspector &cot'Ac4wr Date V\' -l� Vehicle Radio Call Sign M`-( Minimum Equipment Required for Basic Life Support Ambulance Ventilation Equipment (1K Portable suction unit, and a house (fixed system) or backup suction unit, with wide bore tubing, rigid pharyngeal curved suction tip, and soft catheter suction tips to include pediatric sizes 6 fr. through 14 fr. (L ' (LK Bulb syringe. (4 House oxygen with minimum storage capacity of 125 c.f. (M cylinder) and a minimum delivery capability of 2- patients simultaneously through 2 variable flow regulators with capacity at flows of a least 1 -15 L.P.M. (t )/ Portable oxygen system with a minimum storage capacity of 15 c.f.. (D cylinder) and a minimum delivery capability for 1- patient at flows of a least 1 -15 L.P.M. (k Transparent, non - rebreather oxygen masks and nasal cannulas in adult and pediatric sizes. Bag -valve mask resuscitators with oxygen reservoirs and standard 15mm / 2lmm fittings in the following sizes; (t 500cc bag with transparent masks for infant and neonate. (y 750cc bag with transparent masks for children. (lam 1000cc bag with transparent masks for adult. (vY Nasopharyngeal airways in pediatric and adult sizes 12 fr. through 32 fr. (t.V Oropharyngeal airways in adult and pediatric sizes to include: infant, child, small adult, adult and large adult. Patient Assessment Equipment (t K Blood pressure cuffs to include large adult, regular adult, child, infant, and neonatal sizes. (t)V Stethoscope in adult and pediatric sizes. (Q _ Penlight. (i Pulse oximeter with adult and pediatric sensors. 2 Splinting Equipment (V Lower extremity traction splint. (A.-K Upper and lower extremity splints. (l,) Long board with equipment to immobilize the patient from head to heels. (V Scoop, vacuum mattress or equivalent, with appropriate accessories to immobilize . The patient from head to heels. (147 Short board or equivalent, with the ability to immobilize the patient from head to pelvis. (. ' Pediatric immobilization device or adult immobilization device that can be �/ Adapted for pediatric use. ( Adult and pediatric cervical spine and head immobilization equipment. Dressing Materials (t) Bandages - various types and sizes per agency needs and Physician Advisor protocol. (t-3' Multiple dressings (including occlusive dressings), various sizes per ambulance service requirements, needs and Physician Advisor protocol. (t,)' Sterile bum sheets. (y' Alcohol swabs or equivalent. (9 Adhesive tape, per ambulance service requirements, needs, and Physician Advisor protocol. (12) Sterile irrigation solution. Obstetrical Supplies (LK Sterile OB kit to include: towels, 4x4 dressings, umbilical tape or cord clamps, scissors, bulb syringe, sterile gloves, and thermal absorbent blanket. (tr" Neonate stocking cap or equivalent. Miscellaneous Equipment (t4 Heavy bandage scissors, shears or equivalent capable of cutting clothing, belts, boots, etc. (t-r Two working flashlights. (V Blankets and appropriate heat source for the ambulance patient compartment. (l21 Ambulance Service Medical Treatment Protocols. (t-' Oral glucose. (V Spill proof emesis container. (V Universal and /or separate male / female urinals. (+l( Stair Chair 3 Communications Equipment (9 All communications equipment shall be maintained in good working order. The communications equipment must be capable of transmitting and receiving clear voice communications. Two -way communications that will enable the ambulance personnel to communicate with: ( Pr ambulance service's dispatch (y' medical control facility or a physician (or receiving facilities ( j mutual aid agencies. Body Substance Isolation Properly Sized To Fit All Personnel To Include; Non - sterile disposable gloves in small, medium, and large sizes, to include a minimum 1 box of latex free gloves. (1K Protective eyewear. (v) Non- sterile surgical masks. (eY Fluid proof gowns with full - length sleeves or equivalent. (44 Disinfectant spray or wipes for personnel and equipment. (u{ Sharps containers for the appropriate disposal and storage of medical waste and biohazards. (. Particulate respirator, N95 type or better. Safety Equipment (1-{ A set of three (3) warning reflectors. (LK One (1) ten pound (10 lb.) or two (2) five pound (5 lb.) ABC fire extinguishers, with a minimum of one extinguisher accessible from the patient compartment and vehicle exterior and having been serviced within previous year per NFPA 10 section 4. (t. Child safety seat or equivalent (tK Appropriate protective restraints for patients, crew, accompanying family members, and other vehicle occupants. (V Properly secured patient transport system (i.e. wheeled stretcher). ( Triage tags as approved by the Colorado Department of Public Health and Environment. err Restraining devices for all items not in a securable cabinet. (n' Two "NO SMOKING - OXYGEN IN USE" signs, one in cab, one in patient compartment. (vr Reflective vests, coat or equivalent for each member of the crew normally assigned. Pitkin County Required Advanced Life Support Equipment List Inspector Sc eft- +'4'iw Date 11 - a - 10 Vehicle Radio Call Sign M `l Minimum Equipment Requirement for Advanced Life Support Ambulances (v) All Equipment Listed In BLS Equipment list Ventilation Equipment (t- Adult and pediatric endotracheal intubation equipment to include stylets and an endotracheal tube stabilization device and endotracheal tubes uncuffed size range from 2.5 – 5.5, and cuffed size range from 6.0 -8.0 per Physician Advisor protocol. (9/ Laryngoscope and blades, straight, and/or curved of sizes 04. (9 Adult and pediatric magill forceps. (u End tidal CO2 detector or alternative device, approved by the FDA, for determining correct tube placement. Patient Assessment Equipment pc wr.l Dad abl (4 Portable, battery operated cardiac monitor- defibrillator with strip chart recorder and adult and pediatric EKG electrodes and defibrillation capabilities. ( t4' Electronic blood glucose measuring device. Intravenous Equipment (� Adult and pediatric intravenous solutions and administration equipment per Physician Advisor protocol. (4 Adult and pediatric intravenous arm boards. Pharmacological Agents (t� Pharmacological agents and delivery devices per Physician Advisor protocol. (I j� Pediatric "length based" device for sizing drug dosage calculations and sizing equipment. �f As Service Director for Ja/n� y P (,"I �, e , I certify that this ambulance carries the equipment � 4 listed above. This ambulance 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. /L) 6 AL-blot/Ai l� l / /a //o Service Director's Name ignature Date dig y, •. 0 i i t 4 � y v a a � { 44 i " o �... ? i"•'14-1 .a. PITKIN COUNTY AMBULANCE LICENSE NO. 005 -2011 ASPEN AMBULANCE DISTRICT MEDIC 5 The undersigned, representing the Board of County Commissioners (BOCC) of Pitkin County, Colorado, does 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 below, shall be granted any waivers listed below, and shall be valid for the dates listed below, unless revoked by the BOCC pursuant to the provisions of Title Six (Health and Safety - Ambulance Licensing) of the Pitkin County Code and any other applicable Pitkin County ordinance or law of the State of Colorado. Licensee shall comply with all applicable laws and regulations, including but not limited to Article 3.5 of Title 25, Colorado Revised Statutes. RESTRICTIONSICONDITIONS: Not Applicable WAIVERS GRANTED: Not Applicable LICENSE VALID FROM: January 1, 2011 through December 31, 2011 BY AUTHORITY OF THE PITKIN COUNTY = s a RD OF COU COMMISSIONERS: D7)mber 1, 2010 Ll c� ;i , SE- • it • A I ' Leo George Ne, man, air 'C�l. Je -•l e Jones Board of County C. missioners ' �o, , 7fr to the Board .f County Commissioners • PITKIN COUNTY Application for Ambulance Permit Service Information Service Name Aspen Ambulance District Address:C /O Aspen Valley Hospital, 0401 Castle Creek Rd. Aspen, CO 81611 Slrcel/P.O. Cily State Zip Communication: (970) 544 -1571 (970) 544 -1578 \•nice Fax E -Mail Vehicle Information Radio Call Sign Medic 5 License Plate 444HVJ VIN 1 GDJK34618E 198807 4X4 Yes (X) No ( ) Year 2008 Make GMC Type McCoy Miller Where will Vehicle be Stationed Aspen Valley Hospital Waiver Request (Include Reason for Request) gig) Nenvfce Dire y� a Name Signature Date r (Ambulance Inspector Use Only) Valid Insurance Card Yes (d4 No ( ) Valid Registration Card Yes 05 No ( ) Inspection Fee $50.00 6Q Mechanical Condition Certificate Attached fl Required BLS Equipment List Attachecflt Required ALS Equipment List Attached f5 Pass Inspection Fail ( ) Reason for Failure 1 Pithin County Vehicle Safety and Operability Certification Ambulance Service Aspen Ambulance District Vehicle Radio Call Sign _ Medic 5 _ System Acceptable Non Acceptable Comment Tires 06 ( ) Wheels 06 ( Alignment bd ( 1 Suspension P6 ( ) Brake System ) Parking Brake Headlights ,QCI ( 1 Stop/Turn/Brake Lts. (C ( ) Visual Warning Lights P4 ( ) Audible Warning 04 ( ) Electrical System ()Y ( Exhaust Svstem DO ( Fuel System PCS ( ) Glass/Mirrors P4 ( Body & Sheet Metal e‘ ( ) General Present Condition, Excellent 94 Good ( ) Moderate ( ) Poor ( ) Mileage when Inspected ,call J / I, /).z/p 4. (n ( /1 , professing to be a motor vehicle technician with training in the systems listed above, have evaluated the condition of all systems and have found them to be in a safe and working condition. Signet Agency/ om y /rt !O Phone Address Date This evaluation will not guarantee future safety and or operability of this ambulance due to conditions beyond the technician's control. N. dui IL 1 1,110.u,,r, 1 Pitlrin County Required Basic Life Support Equipment List Inspector 5 b-H- Date —a`I U Vehicle Radio Cali Sign Nlo Minimum Equipment Required for Basic Life Support Ambulance ( Ventilation Equipment Portable suction unit, and a house (fixed system) or backup suction unit, with wide bore tubing, rigid pharyngeal curved suction tip, and soft catheter suction (t...)7 tips to include pediatric sizes 6 fr. through 14 fr. Bulb syringe. (House oxygen with minimum storage capacity of 125 c.f. (M cylinder) and a minimum delivery capability oft- patients simultaneously through 2 variable flow regulators with capacity at flows of a least 1 -15 L.P.M. 0..)-- oxygen system with a minimum storage capacity of 15 c.f.. (D cylinder) and a minimum delivery capability for 1- patient at flows of a least 1 -15 L.P.M. (t).V Transparent, non - rebreather oxygen masks and nasal cannulas in adult and pediatric sizes. Bag -valve mask resuscitators with oxygen reservoirs and standard 1Smm / 21mm fittings in the following sizes; (1 14 500cc bag with transparent masks for infant and neonate. (C.) 750cc bag with transparent masks for children. (0/ 1000cc bag with transparent masks for adult. (� Nasopharyngeal airways in pediatric and adult sizes 12 fr. through 32 fr. (� Oropharyngeal airways in adult and pediatric sizes to include: infant, child, small adult, adult and large adult. Patient Assessment Equipment (1,1/ Blood pressure cuffs to include large adult, regular adult, child, infant, and neonatal sizes. (t" Stethoscope in adult and pediatric sizes. (0" Penlight. (a.3" Pulse oximeter with adult and pediatric sensors. 2 Splinting Equipment Of Lower extremity traction splint. (9" Upper and lower extremity splints. (1.' Long board with equipment to immobilize the patient from head to heels. (L,Scoop, vacuum mattress or equivalent, with appropriate accessories to immobilize The patient from head to heels. (\4 / Short board or equivalent, with the ability to immobilize the patient from head to pelvis. (►3" Pediatric immobilization device or adult immobilization device that can be Adapted for pediatric use. ( (Adult and pediatric cervical spine and head immobilization equipment. Dressing Materials (U/" Bandages - various types and sizes per agency needs and Physician Advisor protocol. (tam Multiple dressings (including occlusive dressings), various sizes per ambulance service requirements, needs and Physician Advisor protocol. (i� Sterile burn sheets. (L Alcohol swabs or equivalent. 6,K Adhesive tape, per ambulance service requirements, needs, and Physician Advisor protocol. (K Sterile irrigation solution. Obstetrical Supplies (( Sterile OB kit to include: towels, 4x4 dressings, umbilical tape or cord clamps, scissors, bulb syringe, sterile gloves, and thermal absorbent blanket. (kV Neonate stocking cap or equivalent. Miscellaneous Equipment V Heavy bandage scissors, shears or equivalent capable of cutting clothing, belts, �/ boots, etc. (i. Two working flashlights. (t( Blankets and appropriate heat source for the ambulance patient compartment. (t.Y Ambulance Service Medical Treatment Protocols. (14" Oral glucose. (14 Spill proof emesis container. ( Universal and/or separate male / female urinals. ((4 Stair Chair 3 Communications Equipment (1.-K All communications equipment shall be maintained in good working order. The communications equipment must be capable of transmitting and receiving clear voice communications. Two -way communications that will enable the ambulance personnel to communicate with: (t/ ambulance service's dispatch (ta medical control facility or a physician 47 receiving facilities (c/ mutual aid agencies. Body Substance Isolation Properly Sized To Fit All Personnel To Include; (V Non- sterile disposable gloves in small, medium, and large sizes, to include a minimum 1 box of latex free gloves. Protective eyewear. (C Non- sterile surgical masks. (✓r Fluid proof gowns with full - length sleeves or equivalent. (3 Disinfectant spray or wipes for personnel and equipment. eit Sharps containers for the appropriate disposal and storage of medical waste and biohazards. / (VJ Particulate respirator, N95 type or better. Safety Equipment (44 A set of three (3) waming reflectors. (& ' One (1) ten pound (10 Ib.) or two (2) five pound (5 Ib.) ABC fire extinguishers, with a minimum of one extinguisher accessible from the patient compartment and vehicle exterior and having been serviced within previous year per NFPA 10 section 4. (t / Child safety seat or equivalent (l-r Appropriate protective restraints for patients, crew, accompanying family members, and other vehicle occupants. rr Properly secured patient transport system (i.e. wheeled stretcher). (� Triage tags as approved by the Colorado Department of Public Health and Environment. (1 j/V Restraining devices for all items not in a securable cabinet. (Vr Two "NO SMOKING- OXYGEN IN USE" signs, one in cab, one in patient . compartment. (t4 Reflective vests, coat or equivalent for each member of the crew normally assigned. Pitkin County Required Advanced Life Support Equipment List Inspector aco*` Ar4An t-Ar Date U - k 0 Vehicle Radio Call Sign M5 Minimum Equipment Requirement for Advanced Life Support Ambulances (LK All Equipment Listed In BLS Equipment list Ventilation Equipment (1-K Adult and pediatric endotracheal intubation equipment to include stylets and an endotracheal tube stabilization device and endotracheal tubes uncuffed size range from 2.5 — 5.5, and cuffed size range from 6.0 -8.0 per Physician Advisor protocol. Laryngoscope and blades, straight, and/or curved of sizes 0-4. (4" Adult and pediatric magill forceps. (V End tidal CO2 detector or alternative device, approved by the FDA, for determining correct tube placement. Patient Assessment Equipment (V Portable, battery operated cardiac monitor- defibrillator with strip chart recorder and adult and pediatric EKG electrodes and defibrillation capabilities. (V Electronic blood glucose measuring device. Intravenous Equipment (Lir Adult and pediatric intravenous solutions and administration equipment per Physician Advisor protocol. (b< Adult and pediatric intravenous arm boards. Pharmacological Agents (tom Pharmacological agents and delivery devices per Physician Advisor protocol. (la Pediatric "length based" device for sizing drug dosage calculations and sizing equipment. As Service Director for A4w ,4M (»J ` "c c. , I certify that this ambulance carries the equ ment listed above. This ambulance 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. ;nn itic,ti,-,^e./isw.• 43/0 Service Director's Name S' azure Date a— — 4 > ! C, it° - - lI A. e #11fr '''' w(p �� .�.� T Y w 4 k J f ^ .. Vi Fr. - 5 s • ' S . ':^` a � i ": as F §$� e "f. PITKIN COUNTY AMBULANCE LICENSE NO 006 -2011 ASPEN AMBULANCE DISTRICT MEDIC 6 The undersigned, representing the Board of County Commissioners (BOCC) of Pitkin County, Colorado, does 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 below, shall be granted any waivers listed below, and shall be valid for the dates listed below, unless revoked by the BOCC pursuant to the provisions of Title Six (Health and Safety - Ambulance Licensing) of the Pitkin County Code and any other applicable Pitkin County ordinance or law of the State of Colorado. Licensee shall comply with all applicable laws and regulations, including but not limited to Article 3.5 of Title 25, Colorado Revised Statutes. RESTRICTIONS /CONDITIONS: Not Applicable WAIVERS GRANTED: Not Applicable LICENSE VALID FROM January 1, 2011 through December 31, 2011 BY AUTHORITY OF THE PITKIN COUNTY :'ARD OF COUplTY COMMISSIONERS: Do ember 1, 2010 / N COp ; � qp George Ne, man, Chair a !' ' :tie Jones I Board of County Com .ssione ,�. Jra , ' y \ , to the Board of County Commissioners . . _ PITKIN COUNTY Application for Ambulance Permit Service Information Service Name Aspen Ambulance District Address:C /O Aspen Valley Hospital, 0401 Castle Creek Rd. Aspen, CO 81611 Street/F.O. City Slate Zip Communication: (970) 544 -1571 (970) 544 -1578 Voice Fax E -pull Vehicle Information. Radio Call Sign Medic 6 License Plate 433 -HVJ VIN 1 FDWF37R28EE53559 4X4 Yes (X) No ( ) Year 2008 Make Ford Type McCoy- Miller Where will Vehicle be Stationed Aspen Valley Hospital Waiver Request (Include Reason for Request) (_: / 11 / 6 1- 7-- //AA) Service Dir r•a Name Signature Date (Ambulance Inspector Use Only) Valid surance Card Yes (4 No ( ) Valid egistration Card Yes (Q No ( ) Inspection Fee 550.00 Qc3 Mechanical Condition Certificate Attached t? Required BLS Equipment List Attached (, Required ALS Equipment List Attached (-4 Pass Inspection (A Fail ( ) Reason for Failure 11�a — ifs 1 Pitkin County Vehicle Safety and Operability Certification Ambulance Service Aspen Ambulance District_ Vehicle Radio Call Sign _ Medic 6 System Acceptable Non Acceptable Comment Tires (.Z ( ) Wheels ( ( ) Alignment (30 ( 1 Suspension (?d ( ) Brake System Wj () Parking Brake 04 0 1 Headlights ( ) Stop/Turn/Brake Lts. (0 ( Visual Warning Lights (O ( Audible Warning () ( ) Electrical System OJ ( Exhaust System (x) ( Fuel System Gr) ( 1 Glass/Mirrors P1 ( ) Body & Sheet Metal (t) ( 1 General Present Condition, // Excellent (* Good ( ) Moderate ( ) Poor ( ) Mileage when Inspected 142-°Q I, 144 d-nt( 4 , professing to be a motor vehicle technician with training in the systems listed above, have evaluated the condition of all systems and hav found them to be in a safe and working condition. �, g ict0( #1 ;402- 1) A fkc» COU,r/ `�`" / Signature Agency/ ny Phone Address Date This evaluation will not guarantee future safety and or operability of this ambulance due to conditions beyond the technician's control. ciuc l l mnrci i• n, 1 Pitkin County Required Basic Life Support Equipment List Inspector j(c#} A-r -F-Lur Date 1k -2- - (b Vehicle Radio Call Sign NA Co Minimum Equipment Required for Basic Life Support Ambulance �V� Equipment (am" Portable suction unit, and a house (fixed system) or backup suction unit, with wide bore tubing, rigid pharyngeal curved suction tip, and soft catheter suction tips to include pediatric sizes 6 fr. through 14 fr. (I.7 Bulb syringe. (1.- House oxygen with minimum storage capacity of 125 c.f. (M cylinder) and a minimum delivery capability of 2- patients simultaneously through 2 variable flow regulators with capacity at flows of a least 1 -15 L.P.M. (t)/ oxygen system with a minimum storage capacity of 15 c.f.. (D cylinder) and a minimum delivery capability for 1- patient at flows of a least 1 -15 L.P.M. (tK Transparent, non - rebreather oxygen masks and nasal cannulas in adult and pediatric sizes. Bag -valve mask resuscitators with oxygen reservoirs and standard 15mm / 21mm fittings in the following sizes; {t� 500cc bag with transparent masks for infant and neonate. (17 750cc bag with transparent masks for children. (\)/ 1000cc bag with transparent masks for adult. (tY Nasopharyngeal airways in pediatric and adult sizes 12 fr. through 32 fr. (Q' Oropharyngeal airways in adult and pediatric sizes to include: infant, child, small adult, adult and large adult. Patient Assessment Equipment {+")/ Blood pressure cuffs to include large adult, regular adult, child, infant, and neonatal sizes. (9/ Stethoscope in adult and pediatric sizes. V . Penlight. (AY Puts: oximeter with adult and pediatric sensors. 2 Splinting Equipment (1� Lower extremity traction splint. (1,)- Upper and lower extremity splints. (t4 Long board with equipment to immobilize the patient from head to heels. (t Scoop, vacuum mattress or equivalent, with appropriate accessories to immobilize The patient from head to heels. (4 Short board or equivalent, with the ability to immobilize the patient from head to pelvis. (V Pediatric immobilization device or adult immobilization device that can be Adapted for pediatric use. (t Adult and pediatric cervical spine and head immobilization equipment. Dressing Materials (t-K Bandages - various types and sizes per agency needs and Physician Advisor protocol. I t ( Multiple dressings (including occlusive dressings), various sizes per ambulance service requirements, needs and Physician Advisor protocol. ( Sterile bum sheets. (t4V Alcohol swabs or equivalent. (of Adhesive tape, per ambulance service requirements, needs, and Physician Advisor protocol. (u/ Sterile irrigation solution. Obstetrical Supplies ( Sterile OB kit to include: towels, 4x4 dressings, umbilical tape or cord clamps, scissors, bulb syringe, sterile gloves, and thermal absorbent blanket. (t)/ Neonate stocking cap or equivalent. Miscellaneous Equipment (tr Heavy bandage scissors, shears or equivalent capable of cutting clothing, belts, boots, etc. (rY Two working flashlights. (q Blankets and appropriate heat source for the ambulance patient compartment. (v)' Ambulance Service Medical Treatment Protocols. (4 Oral glucose. (' Spilt proof emesis container. Universal and/or separate male / female urinals. (V Stair Chair 3 Communications Equipment (4/ All communications equipment shall be maintained in good working order. The communications equipment must be capable of transmitting and receiving clear voice communications. Two-way communications that will enable the ambulance personnel to communicate with: (yr ambulance service's dispatch of medical control facility or a physician (y' receiving facilities (t a mutual aid agencies. Body Substance Isolation Properly Sized To Fit All Personnel To Include; (lam Non- sterile disposable gloves in small, medium, and large sizes, to include a minimum 1 box of latex free gloves. (l.]% Protective eyewear. (9— Non- sterile surgical masks. (yam Fluid proof gowns with full - length sleeves or equivalent. (kr Disinfectant spray or wipes for personnel and equipment. (0/ Sharps containers for the appropriate disposal and storage of medical waste and biohazards. (lir Particulate respirator, N95 type or better. Safe Equipment (V A set of three (3) warning reflectors. (One (1) ten pound (10 Ib.) or two (2) five pound (5 Ib.) ABC fire extinguishers, with a minimum of one extinguisher accessible from the patient compartment and vehicle exterior and having been serviced within previous year per NFPA 10 section 4. (Child safety seat or equivalent V Appropriate protective restraints for patients, crew, accompanying family members, and other vehicle occupants. Properly secured patient transport system (i.e. wheeled stretcher). (t4 Triage tags as approved by the Colorado Department of Public Health and Environment. (t-r Restraining devices for all items not in a securable cabinet. ( ) Two "NO SMOKING - OXYGEN IN USE" signs, one in cab, one in patient compartment. er Reflective vests, coat or equivalent for each member of the crew normally assigned. Pitkin County Required Advanced Life Support Equipment List Inspector Se Date tlr a -l0 Vehicle Radio Call Sign M (o Minimum Equipment Requirement for Advanced Life Support Ambulances ( All Equipment Listed In BLS Equipment list Ventilation Equipment (Le Adult and pediatric endotracheal intubation equipment to include stylets and an endotracheal tube stabilization device and endotracheal tubes uncuffed size range from 2.5 — 5.5, and cuffed size range from 6.0 -8.0 per Physician Advisor protocol. (4 - Laryngoscope and blades, straight, and/or curved of sizes 0-4. (tK Adult and pediatric magill forceps. (t( End tidal CO2 detector or alternative device, approved by the FDA, for determining correct tube placement. Patient Assessment Equipment (4 Portable, battery operated cardiac monitor- defibrillator with strip chart recorder and adult and pediatric EKG electrodes and defibrillation capabilities. (v Electronic blood glucose measuring device. Intravenous Equipment l� Adult and pediatric intravenous solutions and administration equipment per Physician Advisor protocol. (v Adult and pediatric intravenous arm boards. Pharmacological Agents (Li Pharmacological agents and delivery devices per Physician Advisor protocol. (< Pediatric "length based" device for sizing drug dosage calculations and sizing equipment. ///� /� As Service Director for /09/W 4 . 6 4- ce , I certify that this ambulance carries the equipment listed above. This ambulance 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. Aim 4) t4.-61All (A-) / //g/ d Service Director's Name S' ature Date r g - • e ^t.. y " h Id\ -.4•Z-4.3-7:7-111 ' T lAJ C `t �� Y" � d .� 1 h� G \Y. V ' l - _' y � Tri S Cj ' n T .v �' rail 4 ......"-Z-..44 � d' OF \ 1 — s. ' 4, mT _,,,-;‘,,i.%,.....,,,.3,:.,-.. sit : PITKIN COUNTY AMBULANCE LICENSE NO 007 -2011 BASALT AND RURAL FIRE PROTECTION DISTRICT MEDIC 41 The undersigned, representing the Board of County Commissioners (BOCC) of Pitkin County, Colorado, does 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 below, shall be granted any waivers listed below, and shall be valid for the dates listed below, unless revoked by the BOCC pursuant to the provisions of Title Six (Health and Safety - Ambulance Licensing) of the Pitkin County Code and any other applicable Pitkin County ordinance or law of the State of Colorado. Licensee shall comply with all applicable laws and regulations, including but not limited to Article 3.5 of Title 25, Colorado Revised Statutes. RESTRICTIONS /CONDITIONS: Not Applicable WAIVERS GRANTED: Not Applicable LICENSE VALID FROM: January 1, 2011 through December 31, 2011 BY AUTHORITY OF THE PITKIN COUNTY B• :RD OF COUN OMMISSIONERS: Debember 1, 2010 _ `x r i / b 4:� lit i Ad 4 1 �' T SEAL ,k _ t /t L Ge N ewman, ha r ' \,k .. Je 'i `a Jones I Board of County Comm . sioners 'I d . ; , a to the Board of ounty Commissioners PITIKIN COUNTY Application for Ambulance Permit Service Information Service Name R45ct I k GAG( � u 4 rI /. e ?tutu_ bu ^ \ s 4 co C+ Address /0 - 3 W. O r iv-. Ccrioor% Co $IGa_3 Street/P.O. City State Zip Communication Voice Fax E-Mail Vehicle Information Radio Call Sign AA 7 I Lic. Plate OS a R14 fL vin# I F b w F 37 F I Y E A G (o ( �� 2 "" 4X4 ('-7 es No () Year 2 000 Make Fara Type Ford AnLtc.nct AL S Where will Vehicle will be Stationed 7_ USchool S 1. ¶3c C $16cy1 Waiver Request (Include Reason for Request) Service Diretior's Name Signature Date (Ambulance Inspector Use Only) Clear CCIC/NCIC Ye () No Valid Insurance Card Y No ( ) Valid Registration Yes No» Registration Card Yes ( No ( ) Inspection Fee $50.00 Mechanical Condition Certificate Attached Required BLS Equipment List Attached 4 Required ALS Equipment List Attached 0) Pass Inspection fl Fail ( ) Reason for Failure plc 144/V5a) 6' /b -27- -/0 Inspector's Name Signature Date 1 MITI7INCOUNTY Vehicle Safety and Operability Certification Ambulance Service Ft'D Radio Call Sign H e_p is 41 System Acceptable Non Acceptable Comment Tires ( ( ) Wheels r) ( ) Alignment Ai)' ( ) Suspension (X■1 ( ) Brake System (V[ ( ) Parking Brake (/ ( ) Headlights ( Stop/Turn/Brake Lts. (VY ( ) Visual Waming Lights (t.1' ( ) Audible Waming (V` ( ) Electrical System V ( ) Exhaust System ( ) Fuel System &' ( ) Glass/Mirrors ( ) Body & Sheet Metal (V ( General Present Condition, Excellent (14Good ( ) Moderate ( ) Poor ( ) Mileage when Inspected 4i,30 3 I, GA lty I-" t Z F tc2 , professing to be a motor vehicle technician with training in the systems listed above, have evaluated the condition of all systems and have found them to be in a safe and working condition. Flew rte<lr.Ar%tc Signature Agency /Company olio - 704- iabl7s iD89 swVn.we_ eAIZho le. 1b'a6fI Phone Address FS i6.)3 Date This evaluation will not guarantee future safety and or operability of this ambulance due to conditions beyond the technician's control. \ ehicle 1il: perk„❑ 1 PITKINCOUATY Required Basic Life Support Equipment List InspectorW« \W\99" Date 101.3 --4° Radio Call Sign iM LI' Minimum Equipment Required for Basic Life Support Ambulance Ventilation Equipment (7� Portable suction unit, and a house (fixed system) or backup suction unit, with wide bore tubing, rigid pharyngeal curved suction tip, and soft catheter suction tips to include pediatric sizes 6 fr. through 14 fr. • Bulb syringe House oxygen with minimum storage capacity of 125 c.f. (M cylinder) and a minimum delivery capability of 2- patients simultaneously through 2 variable flow regulators with capacity at flows of a least 1 -15 L.P.M. 2(4 Portable oxygen system with a minimum storage capacity of 15 c.f.. (D cylinder) and a minimum delivery capability for 1- patient at flows of a least 1 -15 L.P.M. • Transparent, non - rebreather oxygen masks and nasal cannulas in adult and pediatric sizes. Bag -valve mask resuscitators with oxygen reservoirs and standard 15mm / 21 mm fittings in the following sizes; 500cc bag with transparent masks for infant and neonate 750cc bag with transparent masks for children p c)) 1000cc bag with transparent masks for adult co Transparent masks for infants, neonate patients, children and adults. Nasopharyngeal airways in pediatric and adult sizes 12 fr. through 32 fr. fro Oropharyngeal airways in adult and pediatric sizes to include: infant, child, small adult, adult and large adult. Patient Assessment Equipment • Blood pressure cuffs to include large adult, regular adult, child, infant, and neonatal sizes. `- Stethoscope in adult and pediatric sizes. W Penlight. y Pulse oximeter with adult and pediatric sensors. 2 Splinting Equipment Lower extremity traction splint. pcP Upper and lower extremity splints. gq Long board with approved equipment to immobilize the patient from head to heels Q Scoop, vacuum mattress or equivalent, with appropriate accessories to immobilize The patient from head to heels. b, Short board or equivalent, with the ability to immobilize the patient from head to pelvis. la Pediatric immobilization devise or adult spine board that can be adapted for pediatric use. b ig Adult and pediatric cervical spine and head immobilization equipment. Adult and pediatric cervical spine immobilization equipment per Medical Director protocol. Dressing Materials 1)1 Bandages - various types and sizes per agency needs and Physician Advisor protocol. *3 Multiple dressings (including occlusive dressings), various sizes per ambulance service requirements, needs and Physician Advisor protocol. 44' Sterile burn sheets. (' Povidone and alcohol swabs or equivalent. KI) Adhesive tape, per ambulance service requirements, needs, and Physician Advisor protocol. `(4 Sterile irrigation solution. Obstetrical Supplies 99 Sterile OB kit to include: towels, 4x4 dressings, umbilical tape or cord clamps, scissors, bulb syringe, sterile gloves, and thermal absorbent blanket. Neonate stocking cap or equivalent. Miscellaneous Equipment VP Heavy bandage scissors, shears or equivalent capable of cutting clothing, belts, boots, etc. n Two working flashlights. A Blankets and appropriate heat source for the ambulance patient compartment. %FL Ambulance Service Medical Treatment Protocols 0 Oral glucose Activated charcoa N Q Spill proof emisis container L.'.. ■ I I '.I `. 3 1 4 Universal and/or separate male / female urinals r Stair Chair Communications Equipment All communications equipment shall be maintained in good working order. The communications equipment must be capable of transmitting and receiving clear voice communications. Two -way communications that will enable the ambulance personnel to communicate with: Q40 ambulance service's dispatch medical control facility or a physician tfi receiving facilities 41 mutual aid agencies. Body Substance Isolation Properly Sized To Fit All Personnel To Include; IS Non - sterile disposable gloves in small, medium, and large sizes, to include a minimum 1 box of latex free gloves. ca Protective eyewear. 14 Non - sterile surgical masks. I.c) Fluid proof gowns with full- length sleeves or equivalent. ter Disinfectant spray or wipes for personnel and equipment. Sharps containers for the appropriate disposal and storage of medical waste and biohazards. Particulate respirator, N95 type or better. Safety Equipment tp A set of three (3) warning reflectors. One (1) ten pound (10 Ib.) or two (2) five pound (5 Ib.) ABC fire extinguishers, with a minimum of one extinguisher accessible from the patient compartment and vehicle exterior and having been serviced within previous year per NFPA 10 section 4. Child safety seat or equivilant gP Appropriate protective restraints for patients, crew, accompanying family members, and other v.ehicle occupants. f Properly secured patient transport system (i.e. wheeled stretcher). Triage tags as approved by the Colorado Department of Public Health and Environment. VP Restraining devices for all items not in a securable cabinet. 4 p Two "NO SMOKING - OXYGEN IN USE" signs, one in cab one in patient compartment. p Reflective vests, coat or equivalent for each member of the crew normally assigned. BLS Required Equipment PJTKI C0111PTY Required Advanced Life Support Equipment List L .LC ) }Avs e /0-2,1-PD t{ Inpector ' ate Radio Call Sign Minimum Equipment Requirement for Advanced Life Support Ambulances All Equipment Listed In BLS Equipment list Ventilation Equipment Adult and pediatric endotracheal incubation equipment to include stylets and an endotracheal tube stabilization device and endotracheal tubes uncuffed size range from 2.5 — 5.5, and cuffed size range from 6.0 -8.0 per Medical Director protocol. '(G4 Laryngoscope and blades, straight. and/or curved of sizes 0 -4. *0) Adult and pediatric magill forceps. End tidal CO2 detector or alternative device, approved by the FDA, for determining correct tube placement. Patient Assessment Equipment ') Portable, battery operated cardiac monitor- defibrillator with strip chart recorder and adult and pediatric EKG electrodes and defibrillation capabilities. p Electronic blood glucose measuring device. Intravenous Equipment f Adult and pediatric intravenous solutions and administration equipment per Physician Advisor protocol. icy Adult and pediatric intravenous arm boards. Pharmacological Agents Pharmacological agents and delivery devices per Physician Advisor protocol. Pediatric "length based" device for sizing drug dosage calculations and sizing equipment. As Service Director for w 1 ?co.L7c. , I certify that this ambulance carries the equipment listed above. This ambulance 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. 7 1 Physician AdJiisor Name a CO Medical Lie. # Date ( tt 41 i D O Director's Nam Sig ( u e Date r ' 1- \ hi? .1 ,fi A CO N T "- R t R �, fl s ...,� rY PITKIN COUNTY AMBULANCE LICENSE NO. 008 -2011 4 BASALT AND RURAL FIRE PROTECTION DISTRICT MEDIC 42 The undersigned, representing the Board of County Commissioners (BOCC) of Pitkin County, Colorado, does 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 below, shall be granted any waivers listed below, and shall be valid for the dates listed below, unless revoked by the BOCC pursuant to the provisions of Title Six (Health and Safety - Ambulance Licensing) of the Pitkin County Code and any other applicable Pitkin County ordinance or law of the State of Colorado. Licensee shall comply with all applicable laws and regulations, including but not limited to Article 3.5 of Title 25, Colorado Revised Statutes. RESTRICTIONS /CONDITIONS: Not Applicable WAIVERS GRANTED: Not Applicable LICENSE VALID FROM: January 1, 2011 through December 31, 2011 BY AUTHORITY OF THE PITKIN COUNTY B • A 1 OF COUN OMMISSIONERS: December 1, 2010 C� cot, at. l I i OE V d1 j.1 /a George Ne an, C' air q �\ �l� e - ¢` a Jones Board of County Co issioners c . . . C� o the Board of aunty Commissioners r x <} kT? [ l J .. ✓ � 1 .�. ivr< .. N . i eirF .i �.. e`!v FMCS COUNTY Application for Ambulance Permit Service Information Service Name RctSc.IkGr.ct R I i-irt Pro echo., I)1s4r, Address /0$9 3L) Cctrbo -,dc U. Co SCI G0.3 Street/P.O. City State Zip Communication Voice Fax E -Mall Vehicle Information Radio Call Sign M- c(a Lic. Plate 0 - 71 - Q H Vin# IFb(nJF37bO ®ED(a71tS3 4X4(t es No ( ) Year Z OO b Make For ct Type Fore( A r. bu l s'i L Q . ALS Where will Vehicle will be Stationed s 4t& 4-w✓ ( F Z / 0 8-9 S W. I�r I v2 Co. &o cic le CO ?/ -3 Waiver Request (Include Reason for Request) Service Director's Name Signature Date (Ambulance Inspector Use Only) Clear CCIC/NCIC Yes 00 No () Valid Insurance Card Yes (4 No ( ) Valid Registration Yes No ( ) Registration Card Yes (XI No ( ) Inspection Fee $50.00 i4 Mechanical Condition Certificate Attached j5 Required BLS Equipment List Attached p1 Required ALS Equipment List Attached IA Pass Inspection a Fail ( ) Reason for Failure E IQ. 5ET1 tn.-ei /G- 21- -2e lospcemr's Name Signature Date 1 fITKIN COUNTY Vehicle Safety and Operability Certification Ambulance Service ASA ± S- l anA FflRadio Call Sign Kenn. 43... System Acceptable Non Acceptable Comment Tires (V( ( Wheels (ti ( 1 Alignment (Vr ( 1 Suspension (4' ( ) Brake System (9 ( 1 Parking Brake (N' ( Headlights ) Stop/Turn/Brake Lts. (1-4 ( ) Visual Waning Lights (VI ( ) Audible Warning Al ( ) Electrical System ( Exhaust System (1) ( Fuel Svstem t ( Glass/Mirrors ('L) ( Body & Sheet Metal (V ( ) General Present Condition, Excellent (y'Food ( ) Moderate ( ) Poor ( ) Mileage when Inspected 4 4, yeo I, �Atty [-,07 tCt , professing to be a motor vehicle technician with training in the systems listed above, have evaluated the condition of all systems and have found them to be in a safe and working condition. � 7-_ el' -T r \ 2aLA � ■ C n SSA 1� a- ,ALA 1 F F.17. Signature /� 1 Agency /Company � 1 S to get sw1clue CA- t o t al t DA, t t 1/tD Phone Address t Date This evaluation will not guarantee future safety and or operability of this ambulance due to conditions beyond the technician's control. dm. It. In,pcctP 1 PITKIN COUNTY Required Basic Life Support Equipment List InspectoralC 14/k o" Date /c " — / ° Radio Call Sign M — W 2 Minimum Equipment Required for Basic Life Support Ambulance Ventilation Equipment Portable suction unit, and a house (fixed system) or backup suction unit, with wide bore tubing, rigid pharyngeal curved suction tip, and soft catheter suction tips to include pediatric sizes 6 fr. through 14 fr. J Bulb syringe -VD House oxygen with minimum storage capacity of 125 c.f. (M cylinder) and a minimum delivery capability of 2- patients simultaneously through 2 variable flow regulators with capacity at flows of a least 1 -15 L.P.M. Portable oxygen system with a minimum storage capacity of 15 c.f.. (D cylinder) and a minimum delivery capability for 1- patient at flows of a least 1 -15 L.P.M. (o Transparent, non - rebreather oxygen masks and nasal cannulas in adult and pediatric sizes. Bag -valve mask resuscitators with oxygen reservoirs and standard 15mm / 21 mm fittings in the following sizes; 500cc bag with transparent masks for infant and neonate 750cc bag with transparent masks for children 1000cc bag with transparent masks for adult Transparent masks for infants, neonate patients, children and adults. Nasopharyngeal airways in pediatric and adult sizes 12 fr. through 32 fr. Oropharyngeal airways in adult and pediatric sizes to include: infant, child, small adult, adult and large adult. Patient Assessment Equipment i ttP Blood pressure cuffs to include large adult, regular adult, child, infant, and neonatal sizes. 14 Stethoscope in adult and pediatric sizes. 7P Penlight. Pulse oximeter with adult and pediatric sensors. RI 1'.ryr i +hi:in.. 2 Splinting Equipment (>4) Lower extremity traction splint. Upper and lower extremity splints. P Long board with approved equipment to immobilize the patient from head to heels 7 Q Scoop, vacuum mattress or equivalent, with appropriate accessories to immobilize The patient from head to heels. Yom' Short board or equivalent, with the ability to immobilize the patient from head to pelvis. Pediatric immobilization devise or adult spine board that can be adapted for paediatric use. f ' - Adult and pediatric cervical spine and head immobilization equipment. Adult and pediatric cervical spine immobilization equipment per Medical Director protocol. Dressing Materials tp Bandages - various types and sizes per agency needs and Physician Advisor protocol. `� Multiple dressings (including occlusive dressings), various sizes per ambulance �� service requirements, needs and Physician Advisor protocol. Sterile burn sheets. ? Povidone and alcohol swabs or equivalent. (14 Adhesive tape, per ambulance service requirements, needs, and Physician Advisor protocol. t iy Sterile irrigation solution. Obstetrical Supplies 11,e) Sterile OB kit to include: towels, 4x4 dressings, umbilical tape or cord clamps, scissors, bulb syringe, sterile gloves, and thermal absorbent blanket. "lp Neonate stocking cap or equivalent. Miscellaneous Equipment (IP Heavy bandage scissors, shears or equivalent capable of cutting clothing, belts, boots, etc. pc Two working flashlights. (gyp Blankets and appropriate heat source for the ambulance patient compartment. Ambulance Service Medical Treatment Protocols Oral glucose 15}- Activated charcoal ae.,p,, ( 64 Spill proof emisis container i;l 3 Universal and/or separate male / female urinals c3 Stair Chair Communications Equipment 14 All communications equipment shall be maintained in good working order. The communications equipment must be capable of transmitting and receiving clear voice communications. Two -way communications that will enable the ambulance personnel to communicate with: (& ambulance service's dispatch 9 ,9 medical control facility or a physician receiving facilities (i mutual aid agencies. Body Substance Isolation Properly Sized To Fit All Personnel To Include; Non - sterile disposable gloves in small, medium, and large sizes, to include a minimum 1 box of latex free gloves. go Protective eyewear. Non - sterile surgical masks. ND Fluid proof gowns with full - length sleeves or equivalent. Disinfectant spray or wipes for personnel and equipment. 9 Sharps containers for the appropriate disposal and storage of medical waste and biohazards. Particulate respirator, N95 type or better. Safety Equipment t j A set of three (3) warning reflectors. One (1) ten pound (101b.) or two (2) five pound (5 Ib.) ABC fire extinguishers, with a minimum of one extinguisher accessible from the patient compartment and vehicle exterior and having been serviced within previous year per NFPA 10 section 4. fl Child safety seat or equivilant 4 Appropriate protective restraints for patients, crew, accompanying family members, and other vehicle occupants. la Properly secured patient transport system (i.e. wheeled stretcher). Ge "t Triage tags as approved by the Colorado Department of Public Health and Environment. pc) Restraining devices for all items not in a securable cabinet. 4 Two "NO SMOKING - OXYGEN IN USE" signs, one in cab one in patient compartment. ` Reflective vests, coat or equivalent for each member of the crew normally assigned. 1:3LS Required Equipment PITKIN COUNTY Required Advanced Life Support Equipment List Inpector lc 1 /4N>t''J Datel'u `` Call Sign �1 L 2. Minimum Equipment Requirement for Advanced Life Support Ambulances t9 All Equipment Listed In BLS Equipment list Ventilation Equipment 2 Adult and pediatric endotracheal intubation equipment to include stylets and an endotracheal tube stabilization device and endotracheal tubes uncuffed size range from 2.5 — 5.5, and cuffed size range from 6.0 -8.0 per Medical Director protocol. '14) Laryngoscope and blades, straight, and/or curved of sizes 0 -4. °co Adult and pediatric magill forceps. 6 /1 End tidal CO2 detector or altemative device, approved by the FDA, for determining correct tube placement. Patient Assessment Equipment Y ' Portable, battery operated cardiac monitor- defibrillator with strip chart recorder and adult and pediatric EKG electrodes and defibrillation capabilities. ) Electronic blood glucose measuring device. Intravenous Equipment Adult and pediatric intravenous solutions and administration equipment per Physician Advisor protocol. VD Adult and pediatric intravenous arm boards. Pharmacological Agents '41 Pharmacological agents and delivery devices per Physician Advisor protocol. Pediatric "length based" device for sizing drug dosage calculations and sizing equipment. �} As Service Director for Ec YLl r , I certify that this ambulance carries the equipment listed above. This ambulance 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. ) 2 , --t — Pcibert,6) /^'y can CD Zit 4. t hysician Aldvisor Name Sign. CO Medical Lic. # Date r 11 . C_n m f 1 o/ i( /oiio Director's Name Signature r Date c ma, ,- , � � _ ' - - i fir y _ I �-T°, �s'{,�'�,i 4 b R /`F` .• s fi :1-=-4;.. _ ' ' mi l- 1 s s i , -n t. i 4 4:5- rs M r r 1 PITKIN COUNTY AMBULANCE LICENSE NO. 009 -2011 BASALT AND RURAL FIRE PROTECTION DISTRICT MEDIC 43 The undersigned, representing the Board of County Commissioners (BOCC) of Pitkin County, Colorado, does 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 below, shall be granted any waivers listed below, and shall be valid for the dates listed below, unless revoked by the BOCC pursuant to the provisions of Title Six (Health and Safety - Ambulance Licensing) of the Pitkin County Code and any other applicable Pitkin County ordinance or law of the State of Colorado. Licensee shall comply with all applicable laws and regulations, including but not limited to Article 3.5 of Title 25, Colorado Revised Statutes. RESTRICTIONS /CONDITIONS: Not Applicable WAIVERS GRANTED: Not Applicable LICENSE VALID FROM: January 1, 2011 through December 31, 2011 BY AUTHORITY OF THE PITKIN COUNTY B % ' RD OF COU ' COMMISSIONERS: De mber1,2010 r 10.20o Sve 4' pp George New 'an, Ch =ir 's J - =7 e Jones Board of County Com ioners , ;R to the Board of County Commissioners 7m- ' w a '+" ' ' '-- --- , -vrdz. -1' -- ..x.— +rwrkrc suwx ." 3 w � . * '. '''' ''" ' '"" -a .d. wex Axx* , � t w4 PITKIN COUNTY Application for Ambulance Permit Service Information Service Name SGSaI unot EV r“I fir( bis4rt Address I0$9 - 3 L/. Cctrbo»do.(t Co ? /C/ Street/P.O. City Stale Zip Communication Voice Fax E -Mail Vehicle Informatiion Radio Call Sign Neettc H 3 Lic. Plate 05 1— R f t- Vin# I Fb3E3dF ITNA9gS4'S 4X4(�es No ( ) Year IcHG Make Fc oC Type fror f M ta Where will Vehicle will be Stationed 2 `l Z Co T )—ry in Pn lot Meredt f, , co ric Waiver Request (Include Reason for Request) Service Director's Name Signature Date (Ambulance Inspector Use Only) Clear CCICINCIC Yeses No ( ) Valid Insurance Card Yes No ( ) Valid Registration Yes No () Registration Card Yes No ( ) Inspection Fee $50.00 (±4 Mechanical Condition Certificate Attached 00 Required BLS Equipment List Attached Required ALS Equipment List Attached Pass Inspection Fail ( ) Reason for Failure loepectar's Name Signature Date P!77f11V COUNTY Vehicle Safety and Operability ty Certification Ambulance Service -3A5PA- 4 -Runa1 R adio Call Sign Min c 43 System Acce table Non Acceptable Comment Tires ( ) Wheels (4 ( ) Alignment (( ( ) Suspension ( 1r ( ) Brake System (W ( ) Parking Brake (vi ( ) Headlights ) Stop/Turn/Brake Lts. (4I ( ) Visual Warning Lights (Vr ( Audible Warning (\Y ( ) Electrical System (t X' ( ) Exhaust System (VI' ( ) Fuel System (LY ( ) Glass/Mirrors ( ( 1 Body & Sheet Metal (t / ( ) General Present Condition, Excellent (Good ( ) Moderate ( ) Poor ( ) Mileage when Inspected t 3 1 1, GA ay lrs ZE i t t , professing to be a motor vehicle technician with training in the systems listed above, have evaluated the condition of all systems and have found them to be in a safe and working condition. m Flier N4C \S e + dF.Jnol F. Pt Signature Agen y /Company 1 a 4- 06 10 85 �w CAvbtooat ct..3 r'Ob9/0 Phone Address Date This evaluation will not guarantee future safety and or operability of this ambulance due to conditions beyond the technician's control. \ ;il`c.,. 1 PITKIIV COUNTY Required Basic Life Support Equipment List Inspector L1} Date / 70 / O Radio Call Sign My3 Minimum Equipment Required for Basic Life Support Ambulance Ventilation Equipment 7Q Portable suction unit, and a house (fixed system) or backup suction unit, with / wide bore tubing, rigid pharyngeal curved suction tip, and soft catheter suction tips to include pediatric sizes 6 fr. through 14 fr. t17 Bulb syringe C9) House oxygen with minimum storage capacity of 125 c.f. (M cylinder) and a minimum delivery capability of 2- patients simultaneously through 2 variable flow regulators with capacity at flows of a least 1 -15 L.P.M. A Portable oxygen system with a minimum storage capacity of 15 c.f.. (D cylinder) and a minimum delivery capability for 1- patient at flows of a least 1 -15 L.P.M. 1 6 Transparent, non- rebreather oxygen masks and nasal cannulas in adult and pediatric sizes. Bag -valve mask resuscitators with oxygen reservoirs and standard 15mm / 21mm fittings in the following sizes; k iCi 500cc bag with transparent masks for infant and neonate 750cc bag with transparent masks for children 1000cc bag with transparent masks for adult $ Transparent masks for infants, neonate patients, children and adults. by Nasopharyngeal airways in pediatric and adult sizes 12 fr. through 32 fr. (7 Oropharyngeal airways in adult and pediatric sizes to include: infant, child, small adult, adult and large adult. Patient Assessment Equipment '("° Blood pressure cuffs to include large adult, regular adult, child, infant, and neonatal sizes. $j Stethoscope in adult and pediatric sizes. [ " Penlight. Pulse oximeter with adult and pediatric sensors. itl.. PP c.iir; I n, _. 2 Splinting Equipment r Lower extremity traction splint. �(:3 Upper and lower extremity splints. Long board with approved equipment to immobilize the patient from head to heels Scoop, vacuum mattress or equivalent, with appropriate accessories to immobilize The patient from head to heels. 5).1 Short board or equivalent, with the ability to immobilize the patient from head to pelvis. bap Pediatric immobilization devise or adult spine board that can be adapted for pediatric use. 4 3 Adult and pediatric cervical spine and head immobilization equipment. Adult and pediatric cervical spine immobilization equipment per Medical Director protocol. Dressing Materials r Bandages - various types and sizes per agency needs and Physician Advisor protocol. (Q Multiple dressings (including occlusive dressings), various sizes per ambulance service requirements, needs and Physician Advisor protocol. Sterile burn sheets. (p Povidone and alcohol swabs. or equivalent. 0 Adhesive tape, per ambulance service requirements, needs, and Physician Advisor protocol. 0 2 Sterile irrigation solution. Obstetrical Supplies > 4 Sterile OB kit to include: towels, 4x4 dressings, umbilical tape or cord clamps, !! scissors, bulb syringe, sterile gloves, and thermal absorbent blanket. IA Neonate stocking cap or equivalent. Miscellaneous Equipment 22' Heavy bandage scissors, shears or equivalent capable of cutting clothing, belts, boots, etc. IQ Two working flashlights. Blankets and appropriate heat source for the ambulance patient compartment. t Ambulance Service Medical Treatment Protocols ,�Q Oral glucose Activated charcoal 2 i'a.sS ( ) Spill proof emisis container 3 7 3 Universal and/or separate male / female urinals Stair Chair Communications Equipment ty b All communications equipment shall be maintained in good working order. The !` communications equipment must be capable of transmitting and receiving clear voice communications. Two -way communications that will enable the ambulance personnel to communicate with: ambulance service's dispatch b medical control facility or a physician receiving facilities mutual aid agencies. Body Substance Isolation Properly Sized To Fit All Personnel To Include; Non - sterile disposable gloves in small, medium, and large sizes, to include a minimum 1 box of latex free gloves. Protective eyewear. Non - sterile surgical masks. Fluid proof gowns with full - length sleeves or equivalent. 1 Disinfectant spray or wipes for personnel and equipment. 10 Sharps containers for the appropriate disposal and storage of medical waste and biohazards. 6 1 Particulate respirator, N95 type or better. / Safety Equipment A set of three (3) warning reflectors. �J One (1) ten pound (10 lb.) or two (2) five pound (5 Ib.) ABC fire extinguishers, / with a minimum of one extinguisher accessible from the patient compartment and vehicle exterior and having been serviced within previous year per NFPA 10 section 4. bG Child safety seat or equivilant r Appropriate protective restraints for patients, crew, accompanying family members, and other vehicle occupants. (b Properly secured patient transport system (Le. wheeled stretcher). pja Triage tags as approved by the Colorado Department of Public Health and Environment. 10 Restraining devices for all items not in a securable cabinet. 4 .9 Two "NO SMOKING- OXYGEN IN USE" signs, one in cab one in patient compartment. j Reflective vests, coat or equivalent for each member of the crew normally assigned. -- BLS RNquirccl ipmen PITKIN COUNTY Required Advanced Life Support Equipment List Inpector 'sC h n;!Date)u`•`S' Call Sign "i) �f Minimum Equipment Requirement for Advanced Life Support Ambulances ?"(' All Equipment Listed In BLS Equipment list Ventilation Equipment / Adult and pediatric endotracheal intubation equipment to include stylets and an endotracheal tube stabilization device and endotracheal tubes uncuffed size range from 2.5 — 5.5, and cuffed size range from 6.0 -8.0 per Medical Director protocol. fl Laryngoscope and blades, straight, and/or curved of sizes 0-4. Adult and pediatric magill forceps. End tidal CO2 detector or alternative device. approved by the FDA, for determining correct tube placement. Patient Assessment Equipment /3 Portable, battery operated cardiac monitor- defibrillator with strip chart recorder and adult and pediatric EKG electrodes and defibrillation capabilities. Electronic blood glucose measuring device. Intravenous Equipment • Adult and pediatric intravenous solutions and administration equipment per Physician Advisor protocol. 6 Adult and pediatric intravenous arm boards. Pharmacological Agents ` Pharmacological agents and delivery devices per Physician Advisor protocol. ¢) Pediatric "length based" device for sizing drug dosage calculations and sizing equipment. As Service Director for bcscLt 1-r R. crt Pie t4.c 1 s try . I certify that this ambulance carries the equipment listed above. This ambulance 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 l� 2i level. 4-- -65 Av, . (; 2,,,, ij )i h 10 Physician Advts Name Sagnat ' 0 Medical Lic. # Date sWt r A: &tag • 1' II ��ju' � Director's Name . ignature o3 bate