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�� APPLICATION FOR LIC�NS�
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�i,�1 TO OP�RATE Al�tt,U19IvCii SERVICE Ii�
��`L PZTKIN COUNTY, COLORADO
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� n CA 2(83) . '>r.;.;•"
�?? 1. SERVIC� NAME �r lOUNT�s*� +�'�3��-�"��E Se.���c.G
i: 2. ADDRESS ��;� !-}7� �5?�� l�o
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,� 3. PHON� NUFIBER �'.�,S- I I ZO ���a V A�i 7 I�os�n:�A�-
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4. DESC^.IPTION OF EACI[ AML'ULA.7CE to be operated by applican� (include make, �'
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�� model, year of manufacture, Colorado State license number, motor vehicle
� cnassis number):
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� 5, i3OCATION AND DESCRIPTIOD? of piace or places from which the applicant's
ambulance service eperates:
S J�nl3JLAx�cES o�eRAte, y-eom. As��� l�A«�.�wp;•�nc Y'o �s�°c..�
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6. The undersigned, representinr, the applicant herein, certifies, with respect '
to the ambulanca service for whidi this permit is sought (and vehicles
;� to be used hy the applicant in pr.oviding such service) th^t: �
� (a) Each ambuiance listed in paragraph 4 abov assed the C o � :
mo ve e ine� ' n wit��. *l:e precee date of thi ��`
� application. U
� �b) Each ambulance listed iii paragraph 4 above is c^vered by a complying
p�licy as defined in Se�tiun 10-4-7C'3, C.R.S. 1973.
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� (c) �.ch ambulance listed in paragraph 4 above wi�l oe staffed by at least
two persons at every scene of a call for medical ascistance, and at � �.
� :I1 times that a patient is being transportPd, a driver and an �
attendant. Each ambulance driver possesses a valid Colorado Driver s
Lic^_nse and currnnt certificarion in either rlmerican Red Crnss or �'`, .�
Amerir.an lleart Associatiou CYF. Additionaily, each driver holds
. � currenl' certification i.n, at minimum, eitlicr Micri.can Fed Cross � �
Advanced Pirst Aid, Ctash Zn�ury Pianagement, or Trz�uma Pianagemer�t. '�> ' �
i:ach ❑Ctendnnt is a curre::tly cer�iL"ied timcrgency Nedical ':'eclinician, cr
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; , ar. R.^? ial:o is ::c:lici..na11'y t:aine.l and cerciEied in i.rash in�ury .
Pl�aa�ement or Trauma itanage^��nt as descriUa: lbove. �
(d) Each ambulance listed in paraf;r�ph 4 aUave contains equipment which i ,
meets or exceeds tl�e requirements set forth in the "Mibulance �
Inspection Slieet." i
(c) Lach ambul�rc� iisced in parari'a�;i 4 abovr shal� maintain two-way
'� radio communicatlon ca�abiliep wil'li tli� receivin� medioal facilily.
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E: NOTN: Ii. tLe evenl the .�i�rii�,�,c sceks a waivcr from r�..� of `.lw toregoin�;
�� requlreme,:ts, please sCate the naturn. of tlie s�ecific waiver renuested, tl�e
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� nced for L-hc wniver, ar.y �lternate p:oposals, any plan or commitment to mcet
F� ��the requirec:ents, and a stntement as to wl�y, if: granCe�, th� waiv�r will not _
�,, advereely atfect the puulic wclfare:
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{.-:' Date 1 �Z � ��r.-,O 7'���Fe�J
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Signature r;
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GRANT OF FEitPfIT
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5` The undersigned, repr^.senting t:�e Board of County Commissioners of Pitkin
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' -.�:� County, Colora3o, does herc-by grant a license to the above�named a.pplic�nt to '�:
- yrovide ambulance service within Pitkin Cou�ity (and does further :.s�ue a permit {
rY for each ac�bulanee listed in parag.aph 4 of this application Lo be used in (t �
' t rovidin such service), both of which license and (
p g permit(s) shall be valid
through the date of December 31, 14oQ, fro�a the date hereof (unless earlier j
�, revoked by the Board of CoUnty Commissioners pursuant to the pro isions oP
u'; the Board's Resolution ?io. 79-129 or any amendment thereto).
. �� • �
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2a �e�t�c, 19s3 � .
i ` Date of Issuance tE�c
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/ Signature
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�s CHAI2dNAN. BOARD OF COiAJTY CCNMISSIOI�RS
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Title � '• ';
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;�� GRANT OF 51AIVEP.
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�. The undersi�ned, represencing the Board of County Commissioners of Pitkin
'� County, Colorado, does hereUy grant a �oaivPr of license conditions to the above �"�
pA• '.� ,
nawed applicant as stated b�low: � ;,-s:..:�
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"i Date of Issulnce ' j
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Signaturc ;
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