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��� A.^PLICATI(lN rOR LICLI:S�
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�;,� TO OPCRATL•' AMII+rLANCii SLIiVICC IN
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I�� PITKIN COUNTY, COLORADO
� CA 14(83) - '
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�j 1. SERVICC NAt1E .futmc�'Y.f1v�S {��,—}- ��'G'c.�'�C�Q_ . •
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� 2. A➢D[tL5 S (l�ir �'c�� �,J� �1(��eR.G� `�V�Y12�`i� UL� R'(�o�S
� 3. PHONB NUPIBSR ,�- 9a3- z2ia
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� 4. DESCRIPTION OF �ACIl AMIiULAtICE to be operated by applicant (include malce,
� modei, year of manufacture, Colorado State license number, motor veh�cle ;
chassis number):
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� 5. LOCATION AND DESCRIPTION of place or places from which the app23cant's �
� ambulance service operates:
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� 6. The undersigned, representing the applicant herein, certifies, with respect k
� to the ambulance service for which this permit is sought (and vehicles �
,, to be used by the applicant in providing such �ervice) that: ���`-
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(a) Each ambulanca listed in paragraph 4 above has passed the Colorado `''
motor vehicle inspectio.� within thc year preceeding tne date of this �_'� '
a� application. r'�?::
� `• (b) Each ambulance lia*ed in petagraph 4 above is coverc3 by a c_�'�plying
� policy as defined in Sec�iun 10-4-•7�3, C.R.S. 1973.
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(c; �ach amUulance :is�ed in'paragra�h 4 above wi�l ta sta°Fed by at least
� two persons at every �cene of.a call for medical assistanc�, and at �
� all times that a patient is being transported, a driver and an >_ , ".
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� attendant. E:.ch ambulance driver possesses a valid Colorado Driver's �,
Lirense and currenr certi£icacion in either American Fed Cross or ��
American Aeart Association CFI. Additionally, each driver holds
current cercificfltion in, at minimum, either Mier!.can Rnd Cross
Adv�nced First Aid, Crash In�ury M.znagement, or Traurna rian^gcment.
� Eacl: attendanC is a currentl;• certi Pied F:�ergenr.y ptedi.�al Tecliulcian, or �^.
an RN who is additio�ally tt.�ined and cer�ifi.ed in Crash Injury
rtanagement or Trauma ifanageme.it as described abovc. "
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(d) hacl� ambulance listed in paragraph 4 abuve con[ains equi,ment which �
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mects or exceeds the requirements set forth in thc "Ambulance } .
Inspection Shcet." � 4
(e) �aca ambulancc ll:;ted in pnra�raph 4 above s`�all maintlin tceo--w�y 7
r�dio camnunl::atlon capab111tp with the recclving medical tacility. �
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r�� NOTE: In tlie event thc :.,.pl.1c:.:•�t secks a waiver from any of the foregoinF
requiremcnl•s, plcase ::tate tl�e nature oL the specitic waiver requested, tlie
;� necd f�r Cl�c waiver, aay alternate propasals, anv plar� or commitment to mcet
���' thc rnquirements, and a ataemuc•nt as to wLy, if f;ranted, Che waiver will not
�� advers�ly affect the public �•cltare:
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Date �'ll �C.'f �%�z
ignature 4�
- ,�sr.�� ���;,f'- ��c�,� �
� Title
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4w*. G°,ANT OF PEF��SIT 4�
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'!'he undersigned, represei.ting the Board of County C�mmissioners of Pitkin
County, Colorado, doES hereby grant a licei�se to tiie above named applicant to �i
�. provide ambu'_ance service with�n Pitkin County (and does fu-ther issue a permit �
for each ambulance listed in paraotapn 4 of this applicetion to be used in
.; providin� such service), botli of which license and permit(s} shall he valid 'i"�
through t::c date af December 31, 1980, frc,n the date iiereof (unless earlier
revoked by the Board of County Com+nissioners pursuant Co the provisions of
the Baard's Resolution No. 79-129 or any amendment thereto). '
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Date of Issuance 28 ��`�Y� 1983 ��'���_
ignature
� CHAIfdN1N, BOARD OF COUNTSC CCrM1ISSIONERS
� � Title
� �RANT OF WAIVEP.
� The undersigned, representing the Board of.County Co�omissioners of Pitkin `
County, Colorado, does hereby grant a waiver of license conditions to the above ��-:�'•� �
named applicant as stated below: • !�'.�>'�� .
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Date of Issuance
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