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�`` � � � Al'PI,ICA'L'ION I�OR LICrNSr '
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;t�j � TO OPL•'lo1TE A1:BtILAPICG SI:RVICti IN �
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�; PITKIN COUNT7, COLORARO �:. •.
- {1�'�� CA 13(83) ' .
� 1. SERVICC PIAtfIi ��F�EiJ �(Al.lbl 1�Sp�1iAL. AMl3v1.nrlc:�. � .,
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2. ADDRGSS O�a o CASrt� C.R�. !�. �sa�oJ �
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3. PFIDNE NUI•iB�R q2.s'- 11Zc� . �
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!� 6. IIESCRIPTION OP EACiI ATtEULANCE to be operated by appYicant (include make, °
5 model, year of manufacture, Colorado 5[ate li�ense number, motor vehicle '�
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cnassis numbcr):
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`"�' S. LOCATIO:V AND DESCP.IFTIO� of pla�e or pl�ces from which the applic�nt's -
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�� ambulance service operates: • '
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r � 6. 'Piie undersigned, representing the applicant herein, certifies, wiEh respect �
to the aa:bulance service for wbich this permit is sought (and vehicles 'a`
y� to.be used by the applican� in providi.ng such service} that: �
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(a) Each ambu2ance listed �� 'n�,anagr�4 above has passed the Colorado
�-`� motor vehi.cle 'Eiun wiChin the year precceding the date of this
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�-. (b) Each ambulance listed in para�raph 4 above is covered by a complying
}_ po�i�y as defined in �ection i0-4-703, C.R.S. 1973.
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":� (c} E�ch ambulance listed ir. paragraph 4 above_will be sCaffeu by at least �
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two persons at every scene ef a call for medical assistance, and at �".,
�- all times that a paCient is baing transported, a driver and an ?:�`•:;':;. '.
L? attendant. .Eacli ambulance driver possesses a valid Colorado Driver's ��:''',. �
�i � License ac�d c�irrent certificatica in either Aaerican Red Cross or
- Americnn flc�rt Assoc?.atf.on CPP. A.dditionally, each driver holds
c!�[rent ceiti[icat?on in, at minimum, either M�crican Red Cross
, Advanced First Aid, CrasL Injacy hlanagement, �r Trc�uina D[�uagement, i
' &ZCh attend�nt is a currently certified Cmer�;ency l:edical Tecl�nician, or !�
• An PN wLc+ __ adliticr,aliy �raineci and eer�iiLed in CrasL Injucy !
i ttanarement or Trauma 1lanngcmenL as described above.
f (d) Each antbul:�nce lisCed in paca�;r.iph 4 above eontains equipuient wtiich '
mects or c�cceJs thc reqidreiuents set forth in the "Ambulance j
' Inspection Shcet." • � �
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(c)� tiach ami�ulnnrc listed !n ��nraf�rnph 4 lbovic eha11 maintnii; two-way �
r�dio comiuunlcatiou capahi2l[y wltlt che reccivin}; medical Encili[y.
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' � ' - , � 'N7fi:: In thc evcnt th� :�ppLlcrint c:ceka ii wnlvcr [rom any nE tlic [c�reFolnF;
;,, ^� " :rc��ulrcu:enCa, pli•:ivc sL•al•e Llw nnturc'aE tfic r:pecifSc w:itvar rcnuc:ited, L•lic
1:i':: � nced tor c6c �mlvec, any alCcru�tc propns.ili�, :my pl.ut or commttmci�t �o mucl
` y"� thc r�quirnricnt�, nnd 1 �CaL'emen[ as to vhy, ii granted, tlic wnlvcr wi.11 uot
i '' advcrscly aEfect thc puh2lc wclfarc:
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?;`: . Date dV/[�O�y
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Signature
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Title
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�i,,,:�' G?.ANT OF PERt1IT
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4�� The undersigned, repreaenting the Board of County Commissioners oF Pitkin �
' �'°'' Count Colorado, does her�b rant a license to the above na��d a licant to �
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"`%• iovide ambulance setvice within Pitkin CounC fi��
...:j p y (and does.fu�ther isse� a permit
�'� for each ambulance listed in paragraph 4 of this application to be used in i t
_�-�,� providino such service}; bnrh of which license and perr.�it(s) shall be ��lid I *
throu�h th� date of Decer,�ber 31, li3t�, Pron the date hereof (unless earlier �
''�+ revoked by the Board of County Commissioners pursuant to the provisions of '
��?'° the Board's Resolution No. 79-129 or 2r.y 2��ndmenc th�reCo). �
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t'fi 1 • llate of Issuance Z8 EEBRUARY. 1983 ' & �
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_ Signature
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• QiAIA�f�1iV, BOARD OF COUNTY CC�S9ISSiOL�R�:
'� ' Title
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^,� GRANT OF iJAIVER
Th� undcrsi�ned, representing the Board of County Cammi.ssioners of Pitkin p�;•;°':,°'
County, Colorado, does liereby grant a waiver of license conditions to the above � h`�� �
� • named applic�nt as stated helow: • '`'��±'
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Datc oF Issuance • •
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