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Home My WebLink Aboutbocc.con.004.2002CONTRACT # t70 y" 2ofl PITKIN COUNTY AMBULANCE LICENSE FOR: ASPEN AMBULANCE DISTRICT MEDIC 3, MEDIC 4, MEDIC 5, MEDIC 6 GRANT OF LICENSE/PERMIT The undersigned, representing the Board of County Commissioners of Pitkin County, Colorado, do hereby grant a license to the above named applicant to provide ambulance service within Pitkin County. This license shall have upon it any restrictions listed below, shall be granted any waivers listed below, and shall be valid for the dates listed below, unless revoked by the Board pursuant to the provisions of Pitkin County Resolution No. 87-7 and any applicable laws of the State of Colorado. RESTRICTIONS: None WAIVERS GRANTED: None THIS LICENSE IS VALID FROM: January 1, 2002 UNTIL DECEMBER 31, OF THE SAME CALENDAR YEAR y y lllzL /floc/, Patty Clapper, Chairperson Pitkin County Board of County Commissioners APPROVED BY BOCC ON Nil i_3 i s f PITKIN COUNTY APPLICATION FOR AMBULANCE SERVICE LICENSE GENERAL INFORMATION Ambulance Service Name: A spina Tents.. tp vte.Otsrn..'Qx Doing Business As: (t Su o D is crater- c4 P t rww Ca.,Nry) Office Address: Go Asa JFa 44-osptrmt_ o`iot Cra'rtcQA *c,t:_ra. Aspesi,ea. e%lell STREEVLPO1 BOX0 C9 , O)CITY STATE ZIP CODE Office Communications: 44-l5ao Syy-157a Anita/knits isAvAnksarat.oatr VOICE FAX E-MAIL INTERNET SERVICE, INFORMATION Service Area: Asc.tna Arne.,slAmcsa. t>wn - 13o„N me,4ervice Director: Ztelh raD cp. Service Type: PUBLIC X PRIVATE_ BLS_ ALS X EMERGENT % TRANSFER )C. SPECIAL EVENTS )C Number of Ambulances Licensed: ti - ti - S - e) H P1YSICIAN ADVISOR INFORMATION ... hysician Advisor Name: ,1h2 C tios itiaarr"ie=,_z_ Colorado Lice a Numb*: 3oc 3 -,..J Office Address: -lo Mo s'iAau.va 44cra irki.._ cvi a, CAsti- Cs3s:Eicva . RisoE.t.S co. ay. 1 STREET{EO-eo C) Cq, -) CITY STATE ZIP CODE -ice Communications: 5144-1314i 544-159a R iibcsi w-%C. -Fav441d.oFttzr VOICE FAX E-MAIL INTERNET I hereby certify that the information provided In this application is tr.? to the best of my knowledge and belief and contains no willful misrepresentation or falsification. Determination that an A. 'ibulance Service License has been issued based on false information constitutes grounds for license revocation, suspension of operations and possible criminal prosecution. Lim CO/. CA J/UNS° 124 i t / 0 i SER ICE DIRECTOR'S SIGNATURE DATE PNYSICISIGNATURE LATE Date Received: hi2.8/oi EMS Council Comments: (FOR EMS COUNCIL U Ambulance Permits Attached: 1,5 _ Lf NONE EMS Council Recommendation: Rrss Nu` - A Sr utes.- ont.,eaaed EMS Council Chairperson Signature: ccjj (J,qr,, f„� /?�Lti oA NAME DATE Date Referred to BoCC: BoCC Action: Date: P- PJTKLN COUNTY APPLICATION FOR AMBULANCE VEHICLE PERMIT SERVICE INFORMATION Ambulance Service Name: ASpeihi INN" aataarIcfia, D%3mu, r Office Address: go most V1%t%S7 ti,Spl nt._ ,04 o I Criirts CliiISEIc Pa ASooW ca 2)IL=1) STREET/PO BOX CITY STATE ZIP CODE (91'a) C`\l<) Office Communications: 544.- t;so 544 -tS7e As nFW own et 2-POF r-AS PEN .OR13r VOICE FAX E-MAIL INTERNET 'HIC'T,E INFORMATION Memoic.. 3 Designation: Wte CoY to usIy License Plate: Celo%Via0 fa PS AE• I VIN: % &BT T8J Fo 34 12o Chassis Year: Vicki Make: CHE,,y Type: I X II _ III _ 4x4: yes x no _ Insurance Company: Y;pyot tMoe.mu n-y Co Policy Number: Rta To got 3 S - o t Expiration: I/ t i o 1-- Vehicle Location:: AmINutJ,N(r 1).ionccnc o'ta3 CAst-, (Sera fin. +Oet Co. bix.It STREET/PO BOX CITY STATE ZIP CODE -)EQUEST FOR WAIVER (includewqreason for request) 1Y«JF Re9N.Hratriooi Ct}Rt.rEe SERVICE SIGNATURE Iis110of DATE (FOR AMBULANCE INSPECTOR'S USE ONLY) Clear CCIC: Clear NCIC: Insurance Card Present: 1-- Registration Card Present: )( Permit Fee Attached Basic Life Support Required Equipment List Attached k Mechanical Condition Certification Attached ,/ Advance Life Support Provider Required Equipment Certification Attached Comments/Recommendation: l rf1« _C eti� �� INSPECTOR' SIGNATURE POSITION /Z/274/ DATE 3 PITKIN COUNTY ADVANCED LIFE SUPPORT PROVIDER REQUIRED EQUIPMENT CERTIFICATION Ambulance Service Name: Asrc-.► A�.c�., 4aNc,• n‘smca- Ambulance Designation: REOUIRED ALS EQUIPMENT 1. All equipment and supplies listed on the Basic Life Support Required Equipment List. 2. Pediatric diagnostic equipment, age/weight/vital signs chart and drug dosage/equipment size list. ' Adult, pediatric and neo-natal vascular access supplies and equipment as authorized in medical protocols approved for this ambulance service. 4. Adult, pediatric and neo-natal endotracheal intubation equipment as authorized in medical protocols approved for this ambulance service. 5. Cardiac monitor/defibrillator with printer and adult and pediatric monitoring and defibrillating capabilities as authorized in medical protocols approved for this ambulance service. Pharmacological agents and administration equipment and supplies as authorized in medical protocols approved for this ambulance service. 7. Any additional equipment and supplies needed to perform other procedures as authorized in medical protocols approved for this ambulance service. As Physician Advisor for --f cip tM--ftM . & Nta o' irn. cr , I certify that this ambulance carries the equipment and supplies listed above and meets the minimum requirements, established by the State of Colorado and Pitkin County, to provide medical care and transportation of the sick and injured at the Advanced Life Support level. Provision of Advanced Life Support is limited as described in 3-CCR-713-6, Section 4 "Medical Acts Allowed EMTs and Paramedics." 5 COLORADO MEDICAL LICENSE NUMBER y PITKIN COUNTY VEHICLE SAFETY AND OPERABILITY CERTIFICATION 9e. ,`wa Ambulance Service Name: Pk pctbl-AnnnyI&p erg License Plate: ous4,3 Ambulance Number: IA e t, tc. 3 SYSTEMS ACCEPTABLE NOT ACCEPTABLE COMMENTS Wheels & Tires x :id muc i� eering z r Sirsx. IFS , Alignment X Suspension X Service Brakes - /hr s IQK) Parking Brake e0 al/Brc.l Driving Lights Visual Warning Systems Audible Warning Systems X� �{,2 go5,_,/,'-Ir tt Electrical System nu xhaust System Fuel System Glass, Mirrors X Body & Sheet Metal X , ci / v , professing to be a motor vehicle mechanic with training in all of the systems listed above, have evaluated the condition of these systems on the ambulance indicated above and have determined this ambulance to be in safe operating condition. This evaluation does not warrantee the future safety and/or operability of this ambulance due to conditions beyond my control. telE� MECHANICS NAM 3 Rib) Otin tie 9z0-5765 i/ 4o, AGENCY/COMPANY PHONE NUMBER DATE aver PAtn,0 3 P1TKIN COUNTY BASIC LIFE SUPPORT REQUIRED EQUIPMENT LIST SAFETY EQUIPMENT One 2-1/2 lb. or larger ABC fire extinguisher, accessible from the patient compartment and having been \J serviced within the last year per NFPA 10 Section 4. One 5 lb. or larger ABC fire extinguisher, accessible from outside the vehicle and having been serviced / within the last year per NFPA 10 Section 4.. ` Two "NO SMOKING -OXYGEN IN USE" signs, one in cab and one in patient compartment. Flashlight, 2-D cell equivalent or better with spare bulb and batteries or charger. >( Set of 3 reflective warning devices. One reflective vest, coat or equivalent for each member of the crew normally assigned. At least one "SHARPS" container, clearly labeled and easily accessible in the patient compartment. Restraining devices for all items not in a securable cabinet EMERGENCY WARNING EOUIPMENT X Audible warning device (siren) with at least 2 different tones. �c Visual warning devices (lights) with alternating red and/or blue flashing or rotating visible from all sides simultaneously and clear flashing or oscillating visible from front. COMMUNICATIONS EOUIPMENT c Mobile VHF radio with appropriate State, Pitkin County and individual agency frequencies. N/ Mobile UHF radio with appropriate State, Pitkin County, hospital and individual agency frequencies. Portable radio with charger and/or cellular phone for back-up communications with dispatch and hospitals. 4EDICAL EQUIPMENT AND SHPPT,IF,$ Airway: Fixed suction system with wide bore tubing, rigid pharyngeal curved suction tip and soft catheter suction tip with sizes from 5 Fr. to 14 Fr. )c Portable suction system with wide bore tubing, rigid pharyngeal curved suction tip and soft catheter suction tip with sizes from 5 Fr. to 14 Fr. X Bulb Syrinke. —VNasopharyngeal airways in pediatric and adult sizes. *---` Oropharyngeal airways in pediatric and adult sizes. Bite stick or equivalent (oropharyngeal airway). XC Fixed oxygen system with a minimum storage capacity of 125 cubic feet (M cylinder) and a minimum delivery capability for three patients simultaneously at flows of at least 1-15 LPM. Portable oxygen system with a minimum storage capacity of 15 cubic feet (D cylinder) and a minimum delivery capability for one patient at flows of at least 1-15 LPM. )< Infant Bag -Valve -Mask with 500cc bag, reservoir and newborn, infant and child masks. Adult Bag -Valve -Mask with 1000cc bag, reservoir and adult mask. "All mask attachments must be 15mrn V Oxygen masks and cannulas capable of delivering oxygen to adults and infants at flows of at least 1-15 LPM. 1 PITKIN COUNTY BASIC LIFE SUPPORT REQUIRED EQUIPMENT LIST MEDICAL EOUIPMENT ANI) STIPPT,IFS Diagnostic: Blood pressure cuffs in large adult, regular adult, child;: infant and neonatal sizes. `Stethoscopes in adult and pediatric sizes. Pulse oximeter with adult and pediatric sensors. Immobilization & Splinting: One lower extremity traction splint. Upper and lower extremity splints of any type (vacuum, air, SAM, wire, board, etc.). Long spineboard, vacuum mattress or equivalent with appropriate accessories to immobilize patients from head to heels. y _ One orthopedic stretcher (scoop). yShort spineboard, ICED or equivalent with appropriate straps to immobilize patients from head to pelvis. - t, Pediatric spineboard or adult spineboard adaptable to pediatric use. Adult and pediatric sized head immobilization equipment for each long spineboard and/or scoop stretcher carried. )( Rigid cervical immobilization collars in tall adult through infant sizes. Wound Care: 4 Bandages, including but not limited to, roller gauze, triangular and elastic per agency needs. ) -- Dressings, including but not limited to, trauma, ABD, gauze, occlusive and bandaids per agency needs. Sterile bum sheets. Povidone and alcohol swabs or equivalent. Adhesive tape, including but not limited to, 1" and 2" per agency needs. x_ Sterile irrigation solution. ,bstetrical Supplies: 1 Sterile OB kit to include: towels, 4x4s, umbilical tape or cord clamps, scissors, bulb syringe, sterile v blanket and sterile gloves. Silver Swaddler and stocking cap or equivalents. Infer 'on Control: Exam gloves in small, medium and large sizes. '1 Face and eye shields. '- Fluid -proof gowns with'full length sleeves or equivalent. y Disinfectant spray or wipes for personnel and equipment. Miscellaneous: "- Oral glucose. y., Activated charcoal. Heavy duty bandage scissors or shears capable of tutting clothing, belts, boots, etc. )c Spill -proof emesis container with at least 1 liter capacity. Y universal or separate male and female urinals. V Multi -level wheeled gurney 1 y Stair chair or equivalent. J Blankets. Patient compartment heater. 2 PITK1N COUNTY Met c.y SERVICE INFORMATION Ambulance Service Name: APPLICATION FOR AMBULANCE VEHICLE PERMIT Fso et4 Ptntsu LANcc SDI Srra.\C'T Office Address: CI-0 A'arta'saucy 4 mkt — o'{o I C,m r.rLe- Crie_ Q'o p5p�,t, Co. eb t)I STREET/PO BOX CITY STATE ZIP CODE (ctlo) ('no) Office Communications: 5M4— 15so 54'4 —tF'I R AS In tstiAeN.1 c P.xl HAsnee 1. On. C.- VOICE FAX E-MAIL INTERNET 'HICT,F, INFORMATION Pnt_z‘c.y aw. Q„xw Designation:Wi4g.1.. Cnont. License Plate: 'Ae3 p.3 0' VIN: 1 c -1314'J 34Iy BtcF 301 ►13 Chassis Year: 19 gi Make: C Rea) I Type: I II _ III 4x4: yes _ no Insurance Company: RoyAt_ IN or=rv. N I ri t,.. Policy Number: ar op o 11 s - a 1 Expiration: 1 I I I en__ Vehicle Location: : AMCso lratcia 9.1,0+Pme t. c 0 `t 0 S CAsrta. Cat._ Pi -a Aspc w C 0 t\ e It STREET/PO BOX CITY STATE ZIP CODE �LEQUEST FOR WAIVER (include reason for request) N cM . Tce,4.1/41ft:s,E.,=, SERVICE DIRECTOR'S SIGNATURE 12-J11/01 DATE Clear CCIC: Clear NCIC: Permit Fee Attached (FOR AMBULANCE INSPECTOR'S USE ONLY) Insurance Card Present: N.. Registration Card Present: 7- X Basic Life Support Required Equipment List Attached )C Mechanical Condition Certification Attached )< Advance Life Support Provider Required Equipment Certification Attached Comments/Recommendation: a55 //iiii4i,frbe_ 4-et_ _5K'fpb //l,��Gbee 4,dlf/:ty/ 'zA /or INSPE R'S SIGNATURE POSITION DATE PITKIN COUNTY ADVANCED LIFE SUPPORT PROVIDER REQUIRED EQUIPMENT CERTIFICATION Ambulance Service Name: At!pe. APA12,,i td..N t snt er Ambulance Designation: nnuo,e.“1/4 REOUIRED ALS EOUIPMENT I. All equipment and supplies listed on the Basic Life Support Required Equipment List. 2. Pediatric diagnostic equipment, age/weight/vital signs chart and drug dosage/equipment size list. Adult, pediatric and neo-natal vascular access supplies and equipment as authorized in medical protocols approved for this ambulance service. 4. Adult, pediatric and neo-natal endotracheal intubation equipment as authorized in medical protocols approved for this ambulance service. 5. Cardiac monitor/defibrillator with printer and adult and pediatric monitoring and defibrillating capabilities as authorized in medical protocols approved for this ambulance service. s. Pharmacological agents and administration equipment and supplies as authorized in medical protocols approved for this ambulance service. 7. Any additional equipment and supplies needed to perform other procedures as authorized in medical protocols approved for this ambulance service. As Physician Advisor for A-)ncss► AMKvlwNu6 C>11,mer I certify that this ambulance carries the equipment and supplies listed above and meets the minimum requirements, established by the State of Colorado and Pitkin County, to provide medical care and transportation of the sick and injured at the Advanced Life Support level. Provision of Advanced Life Support is limited as described in 3-CCR-713-6, Section 4 "Medical Acts Allowed EMTs and Paramedics." PHYSICIA LCWIS•R'S SIG COLORADO MEDICAL LICENSE NUMBER DATE PITKIN COUNTY VEHICLE SAFETY AND OPERABILITY CERTIFICATION Cie . P'nuM Ambulance Service Name: Asocbt -A-nn u•tpwu¢ License Plate: `ts 3 fr 3 o Ambulance Number: Mans_. SYSTEMS ACCEPTABLE NOT ACCEPTABLE COMMENTS Wheels & Tires X Elf Irdnu) L,ers an Bering X Alignment X Suspension X Service Brakes X Parking Brake X Driving Lights X Visual Warning Systems X Audible Warning Systems / Electrical System x Exhaust System X re A n spa Jl AFly Fuel System Glass, Mirrors Th, E� Ow r & td cueing) Body & Sheet Metal X 72 ly ( tui-iL5 4'pp itto ale , professing to be a motor vehicle mechanic with training in all of the s s ms listed a v , ha evaluated the condition of these systems on the ambulance indicated above and have determined this ambulance to be in safe operating condition. This evaluation does not warrantee the future safety and/or operability of this ambulance due to conditions beyond my control. MECHANIC'S AN MEfitj (L/ 720- AGENCY/COMPAN'r/ PHONE NUMBER DATE /� PITKIN COUNTY BASIC LIFE SUPPORT REQUIRED EQUIPMENT LIST SAFETY EQUIPMENT )c One 2-1/2 lb. or larger ABC fire extinguisher, accessible from the patient compartment and having been serviced within the last year per NFPA 10 Section 4.` N/... One 5 Ib. or larger ABC fire extinguisher, accessible from outside the vehicle and having been serviced within the Last year per NFPA 10 Section 4.. X Two "NO SMOICING-OXYGEN 1N USE" signs, one in cab and one in patient compartment. Flashlight, 2-D cell equivalent or better with spare bulb and batteries or charger. Set of 3 reflective warning devices. One reflective vest, coat or equivalent for each member of the crew normally assigned. At least one "SHARPS" container, clearly labeled and easily accessible in the patient compartment. Restraining devices for all items not in a securable cabinet EMERGENCY WARNING EQUIPMENT Audible warning device (siren) with at least 2 different tones. Visual warning devices (lights) with alternating red and/or blue flashing or rotating visible from all sides simultaneously and clear flashing or oscillating visible from front. COMMUNICATIONS EQUIPMENT l`_ Mobile VHF radio with appropriate State, Pitkin County and individual agency frequencies. � Mobile UHF radio with appropriate State, Pitkin County, hospital and individual agency frequencies. Portable radio with charger and/or cellular phone for back-up communications with dispatch and hospitals. 4EDICAL EQUIPMENT AND SUPPLIES Airway: 'y Fixed suction system with wide bore tubing, rigid pharyngeal curved suction tip and soft catheter suction tip with sizes from 5 Fr. to 14 Fr. "i Portable suction system with wide bore tubing, rigid pharyngeal curved suction tip and soft catheter suction tip with sizes from 5 Fr. to 14 Fr. X Bulb Syringe. Nasopharyngeal airways in pediatric and adult sizes. Oropharyngeal airways in pediatric and adult sizes. Bite stick or equivalent (oropharyngeal airway). Fixed oxygen system with a minimum storage capacity of 125 cubic feet (M cylinder) and a minimum delivery capability for three patients simultaneously at flows of at least 1-15 LPM. Y Portable oxygen system with a minimum storage capacity of 15 cubic feet (D cylinder) and a minimum delivery capability for one patient at flows of at least 1-15 LPM. /Clnfant Bag -Valve -Mask with 500cc bag, reservoir and newborn, infant and child masks. �C Adult Bag -Valve -Mask with 1000cc bag, reservoir and adult mask. "All mask attachments must be 15mm" X Oxygen masks and cannulas capable of delivering oxygen to adults and infants at flows of at least 1-15 LPM. 1 PITKIN COUNTY BASIC LIFE SUPPORT REQUIRED EQUIPMENT LIST MEDICAL FOUIPMENT AND SUPPT TES Diagnostic: Blood pressure cuffs in large adult, regular adult, child, infant and neonatal sizes. Stethoscopes in adult and pediatric sizes. Pulse oximeter with adult and pediatric sensors. Imniobilization & Splinting: x One lower extremity traction splint. Xi Upper and lower extremity splints of any type (vacuum, air, SAM, wire, board, etc.). ^C Long spineboard, vacuum mattress or equivalent with appropriate accessories to immobilize patients from head to heels. I- One orthopedic stretcher (scoop). m Short spineboard, KED or equivalent with appropriate straps to immobilize patients from head to pelvis. -)( Pediatric spineboard or adult spineboard adaptable to pediatric use. Adult and pediatric sized head immobilization equipment for each long spineboard and/or scoop stretcher carried. iA Rigid cervical immobilization collars in tall adult through infant sizes. Wound Care: Bandages, including but not limited to, roller gauze, triangular and elastic per agency needs. .) X Dressings, including but not limited to, trauma, ABD, gauze, occlusive and bandaids per agency needs. ')'-Sterile bum sheets. x Povidone and alcohol swabs or equivalent. "'Adhesive tape, including but not limited to, 1" and 2" per agency needs. Sterile irrigation solution. .ostetrical Supplies: Sterile OB kit to include: towels, 4x4s, umbilical tape or cord clamps, scissors, bulb syringe, sterile blanket and sterile gloves. Silver Swaddler and stocking cap or equivalents. Infection Control: Exam gloves in small, medium and large sizes. ✓ Face and eye shields. Fluid -proof gowns with full length sleeves or equivalent. y, Disinfectant spray or wipes for personnel and equipment. Miscellaneous: 14, Oral glucose. 2C Activated Charcoal. x Heavy duty bandage scissors or shears capable of cutting clothing, belts, boots, etc. Spill -proof emesis container with at least 1 liter capacity. universal or separate male and female urinals. �C Multi-level.wheeled gurney )(Stair chair or equivalent. .a(Blankets. k Patient compartment heater. 2 PITKIN COUNTY APPLICATION FOR AMBULANCE VEHICLE PERMIT SERVICE INFORMATION] Ambulance Service Name: asn t.l q„ ,e,„t a.,ca t:)%sr0,„T- Office Address: Cho Aye as v P'ue-,), Rosy„-pL. oy o I c farr1a. Vaatm4. 0.0. As+� Co. et t..l1 STREET/POet OX �� 1 CITY STATE 1 ZIP CODE Office Communications: 544 - try so 544- t 51 a As es vv n Qf v,i ts -qsp eal -oa. VOICE FAX E.-MAIL aINTERNEr ,HICT1F INFORMATION nAto�c.s Coto. Plr,cs74 Designation: w.. Nfte _Cor-4-4.License Plate: St3'ira30 VIN: l Crt3SK?iM ZR Ltsyq1. Chassis Year: 19 qt.( Make: Cwec.N y Type: I II _ III _ 4x4: yes no Insurance Company: RoywusaemN,cy Co. Policy Number: RHToy o t s 5- o l Expiration: t l trot Vehicle Location:: Ar.,rsa11atit+! , Pn,,, s 04 o 3 cFascyr C a tc -spiv Ci RI ti k STREET/PO BOX CITY STATE ' ZIP CODE • ,:EOUEST FOR WAIVER (include reason for request) N otie- RC471�)6S.r=A C✓,et.urXt lZ�I Ile I SERVICE DIRBCTOR'S SIGNATURE DATE (FOR AMBULANCE INSPECTOR'S USE ONLY) Clear CCIC: Clear NCIC: Insurance Card Present: X Registration Card Present: x `\ Permit Fee Attached IN Basic Life Support Required Equipment List Attached I Mechanical Condition Certification Attached )C Advance Life Support Provider Required Equipment Certification Attached Comments/Recommendation: calla INSPECTOR'S SIGNATURE POSITION 6761- P ftta_e £' pz ra i2,/27fo7 DATE /3 PITKIN COUNTY ADVANCED LIFE SUPPORT PROVIDER REQUIRED EQUIPMENT CERTIFICATION Ambulance Service Name: kn*Eta-Arnr'n tame*. D,sratn- Ambulance Designation: Ma,c 5 REQUIRED ALS EOUIPMENT 1. All equipment and supplies listed on the Basic Life Support Required Equipment List. 2. Pediatric diagnostic equipment, age/weight/vital signs chart and drug dosage/equipment size List. ' Adult, pediatric and neo-natal vascular access supplies and equipment as authorized in medical protocols approved for this ambulance service. 4. Adult, pediatric and neo-natal endotracheal intubation equipment as authorized in medical protocols approved for this ambulance service. 5. Cardiac monitor/defibrillator with printer and adult and pediatric monitoring and defibrillating capabilities as authorized in medical protocols approved for this ambulance service. c. Pharmacological agents and administration equipment and supplies as authorized in medical protocols approved for this ambulance service. 7. Any additional equipment and supplies needed to perform other procedures as authorized in medical protocols approved for this ambulance service. As Physician Advisor for NATf e1 AMr1Ait.a.N(+r- Dam.e.r , I certify that this ambulance carries the equipment and supplies listed above and meets the minimum requirements, established by the State of Colorado and Pitkin County, to provide medical care and transportation of the sick and injured at the Advanced Life Support level. Provision of Advanced Life Support is limited as described in 3-CCR-713-6, Section 4 "Medical Acts Allowed EMTs and Paramedics." )99--5 /Z/z�/ COLORADO MEDICAL LICENSE NUMBER ,BATE Y PITKIN COUNTY VEHICLE SAFETY AND OPERABILITY CERTIFICATION Cato_ Ambulance Service Name: (\s fe,,t -qr tul.�� cLicense Plate: ay &3 o Ambulance Number: Mct:,e 5 SYSTEMS ACCEPTABLE NOT ACCEPTABLE COMMENTS Wheels & Tires // eering ,/ Alignment V Suspension V Service Brakes /7 Parking Brake ✓ Driving Lights //' Visual Warning Systems ,/ Audible Warning Systems ✓ Electrical System tt- Exhaust System ✓ Fuel System v Glass, Mirrors t/' Body & Sheet Metal 1, I i tin, ! /6Tlzn,r, x , professing to be a motor vehicle mechanic with training in all of the systems listed abos4(hevaluated the condition of these systems on the ambulance indicated above and have determined this ambulance to be in safe operating condition. This evaluation does not warrantee the future safety and/or operability of this ambulance due to conditions beyond my control. CHANIC'S NAME AGENCY/COMPA'Y PHONE NUMBER DATE PITKIN COUNTY BASIC LIFE SUPPORT REQUIRED EQUIPMENT LIST MEDICAL EQUIPMENT ANI) Si1PPiIFS Diagnostic: Blood pressure cuffs in large adult, regular adult, child; infant and neonatal sizes. / , Stethoscopes in adult and pediatric sizes. +v Pulse oximeter with adult and pediatric sensors. Immobilization & Splinting: One lower extremity traction splint. Upper and lower extremity splints of any type (vacuum, air, SAM, wire, board, etc.). Long spineboard, vacuum mattress or equivalent with appropriate accessories to immobilize patients from head to heels. One orthopedic stretcher (scoop). Short spineboard, KED or equivalent with appropriate straps to immobilize patients from head to pelvis. Pediatric spineboard or adult spineboard adaptable to pediatric use. )d Adult and pediatric sized head immobilization equipment for each long spineboard and/or scoop stretcher carried. 5C Rigid cervical irmobilization collars in tall adult through infant sizes. Wo{md Care: ✓ Bandages, including but not limited to, roller gauze, triangular and elastic per agency needs. ) ) Dressings, including but not limited to, trauma, ABD, gauze, occlusive and bandaids per agency needs. terile burn sheets. V Povidone and alcohol swabs or equivalent. ✓ Adhesive tape, including but not limited to, 1" and 2" per agency needs. v Sterile irrigation solution. ,ostetrical Supplies: ✓ Sterile OB kit to include: towels, 4x4s, umbilical tape or cord clamps, scissors, bulb syringe, sterile blanket and sterile gloves. V Silver Swaddler and stocking cap or equivalents. Infection Control: Exam gloves in small, medium and large sizes. Face and eye shields. / Fluid -proof gowns with full length sleeves or equivalent. '/Disinfectant spray or wipes for personnel and equipment. Mi ellaneous: Oral glucose. is Activated charcoal. 2< Heavy duty bandage scissors or shears capable of cutting clothing, belts, boots, etc. y. Spill -proof emesis container with at least 1 liter capacity. k universal or separate male and female urinals. Multi -level. wheeled gurney l_ Stair chair or equivalent. J X Blankets. Patient compartment heater. 2 /G t\aa c, 5 PITKIN COUNTY BASIC LIFE SUPPORT REQUIRED EQUIPMENT LIST SAFETY EQUIPMENT l! One 2-1/2 lb. or larger ABC fire extinguisher, accessible from the patient compartment and having been serviced within the last year per NFPA 10 Section 4.` ,( One 5 lb. or larger ABC fire extinguisher, accessible from outside the vehicle and having been serviced within the Last year per NFPA 10 Section 4.. `f Two "NO SMOKING -OXYGEN 1N USE" signs, one in cab and one in patient compartment. 1 Flashlight, 2-D cell equivalent or better with spare bulb and batteries or charger. Set of 3 reflective warning devices. 2( One reflective vest, coat or equivalent for each member of the crew normally assigned. At least one "SHARPS" container, clearly labeled and easily accessible in the patient compartment. Restraining devices for all items not in a securable cabinet FMFI;GENCY WARNING EQUIPMENT \/Audible warning device (siren) with at least 2 different tones. i( Visual warning devices (lights) with alternating red and/or blue flashing or rotating visible from all sides simultaneously and clear flashing or oscillating visible from front. SOMMTTNICATIONS EQUIPMENT Mobile VHF radio with appropriate State, Pitkin County and individual agency frequencies. V(Mobile UHF radio with appropriate State, Pitkin County, hospital and individual agency frequencies. Portable radio with charger and/or cellular phone for back-up communications with dispatch and hospitals. 4EDICAL EQUIPMENT AND STIPPLIES Airway: X Fixed suction system with wide bore tubing, rigid pharyngeal curved suction tip and soft catheter suction tip with sizes from 5 Fr. to 14 Fr. )( Portable suction system with wide bore tubing, rigid pharyngeal curved suction tip and soft catheter suction tip with sizes from 5 Fr. to 14 Fr. 1' Bulb Syringe. Nasopharyngeai airways in pediatric and adult sizes. Oropharyngeal airways in pediatric and adult sizes. Y Bite stick or equivalent (oropharyngeal airway). Fixed oxygen system with a minimum storage capacity of 125 cubic feet (M cylinder) and a minimum delivery capability for three patients simultaneously at flows of at least 1-15 LPM. X Portable oxygen system with a minimum storage capacity of 15 cubic feet (D cylinder) and a minimum xdelivery capability for one patient at flows of at least 1-15 LPM. Infant Bag -Valve -Mask with 500cc bag, reservoir and newborn, infant and child masks. X Adult Bag -Valve -Mask with 1000cc bag, reservoir and adult mask. ''''All mask attachments must be 15mm•• Oxygen masks and cannulas capable of delivering oxygen to adults and infants at flows of at least 1-15 LPM. 1 i2 PITKIN COUNTY Policy Number: R47 oat Q I S S- 01 Expiration: t( I J to, , EQUEST FOR WAIVER (include reason for request) NoNe SERVICE INFORMATION Ambulance Service Name: APPLICATION FOR AMBULANCE VEHICLE PERMIT Asitsi Afr csu tAmku E . nu rn'Q r Office Address: q0 AspDtot 414u.-i fie 1p,rat__. 04-o1 CAsrip.cu Dn. Popeet,Cc. a1ta11 STREET/POBOX CITY STATE ZIP CODE ( ` 1a) en-1 Office Communications: soy-15So 544-1518 krp.aAmaaAUK-A>p rml,oats- VOICE FAX E-MAIL INtERNET ,TTTCT.F, INFORMATION Mttit.G Designation: Near(' NI C��,o,.-wH License Plate: '{ t, S pt 3 0' VIN: C- 31 1\ N E.R etes t -i-- Chassis Year: ► q 1 ei Make: Fe, m a VA Type: I _ II _ III 4x4: yes no Insurance Company: 1t,o.i A L. lwa Arcr. r,.1 Cn Vehicle Location:: Anne,. paA.r, 1/�sy\VluAcic FiAft. Srntat osro3C/asTtt.e _ STREET/PO BOX CITY STATE ZIP CODE A'peal, Co 811, 11 Cot lA.) A 1i.c5n--) / Z-/ 1 i o 1 SERVICE DIRE OSIGNATURE DATE (FOR AMBULANCE INSPECTOR'S USE ONLY) Clear CCIC: Clear NCIC: Insurance Card Present: Registration Card Present: / Nk Permit Fee Attached �! Basic Life Support Required Equipment List Attached a/ Mechanical Condition Certification Attached Advance Life Support Provider Required Equipment Certification Attached Comments/Recommendation:AS 2' (lo C`_— 5wr-P ineel2ed.e tth,vav /z/27/ / INSPECT'S SIGNATURE POSITION DATE /8 PITKIN COUNTY ADVANCED LIFE SUPPORT PROVIDER REQUIRED EQUIPMENT CERTIFICATION Ambulance Service Name: Asn»►-Atnn„LoNwr, r,sr Ambulance Designation: Me;mlc.ce REQUIRED ALS EQUIPMENT 1. All equipment and supplies listed on the Basic Life Support Required Equipment List. 2. Pediatric diagnostic equipment, age/weight/vital signs chart and drug dosage/equipment size list. ' Adult, pediatric and neo-natal vascular access supplies and equipment as authorized in medical protocols approved for this ambulance service. 4. Adult, pediatric and neo-natal endotracheal intubation equipment as authorized in medical protocols approved for this ambulance service. 5. Cardiac monitor/defibrillator with printer and adult and pediatric monitoring and defibrillating capabilities as authorized in medical protocols approved for this ambulance service. s. Pharmacological agents and administration equipment and supplies as authorized in medical protocols approved for this ambulance service. 7. Any additional equipment and supplies needed to perform other procedures as authorized in medical protocols approved for this ambulance service. As Physician Advisor for /�� Ah� . t�,z,,,,er , I certify that this ambulance carries the equipment and supplies listed above and meets the' minimum requirements, established by the State of Colorado and Pitkin County, to provide medical care and transportation of the sick and injured at the Advanced Life Support level. Provision of Advanced Life Support is limited as described in 3-CCR-713-6, Section 4 "Medical Acts Allowed EMTs and Paramedics." PHYSIC ADVIS°Re 3s3 COLORADO MEDICAL LICENSE NUMBER / 12/6 DATE /9 PITKIN COUNTY VEHICLE SAFETY AND OPERABILITY CERTIFICATION PInw Ambulance Service Name: -Avsneasi Nen o.vvaNrc License Plate: (it S 3 cAmbulance Number: Mac. SYSTEMS ACCEPTABLE NOT ACCEPTABLE COMMENTS Wheels & Tires J eering Alignment t' Suspension Service Brakes Parking Brake // Driving Lights ,.� Visual Warning Systems Audible Warning Systems Electrical System xhaust System , 4/ Fuel System t/ Glass, Mirrors t/ Body & Sheet Metal 1, c!<tiLe-l'et , professing to be a motor vehicle mechanic with training in all of the systems listed above, have evalua d the condition of these systems on the ambulance indicated above and have determined this ambulance to be in safe operating condition. This evaluation does not warrantee the future safety and/or operability of this ambulance due to conditions beyond my control. (,�-�J\`'/�mil (l 7 MECHANIC'S NA E 9 go 9„to-s7z4s— /2/ 4/ AGENCY/COMPANY PHONE NUMBER DATE 9d M1 t PITKIN COUNTY BASIC LIFE SUPPORT REQUIRED EQUIPMENT LIST SAFETY EOUIPMENT 1' One 2-1/2 lb. or larger ABC fire extinguisher, accessible from the patient compartment and having been serviced within the last year per NFPA 10 Section 4.' '$ One 5 Ib. or larger ABC fire extinguisher, accessible from outside the vehicle and having been serviced within the last year per NFPA 10 Section 4.. Two "NO SMOKING -OXYGEN IN USE" signs, one in cab and one in patient compartment. Flashlight, 2-D cell equivalent or better with spare bulb and batteries or charger. )( Set of 3 reflective warning devices. X One reflective vest, coat or equivalent for each member of the crew normally assigned. y. At least one "SHARPS" container, clearly labeled and easily accessible in the patient compartment. )( Restraining devices for all items not in a securable cabinet EMERGENCY WARNING FOUIPMENT k. Audible warning device (siren) with at least 2 different tones. XVisual warning devices (lights) with alternating red and/or blue flashing or rotating visible from all sides simultaneously and clear flashing or oscillating visible from front. COMMUNICATIONS EQUIPMENT "'1 < Mobile VHF radio with appropriate State, Pitkin County and individual agency frequencies. J X Mobile UHF radio with appropriate State, Pitkin County, hospital and individual agency frequencies. --)4 Portable radio with charger and/or cellular phone for back-up communications with dispatch and hospitals. i4EDICAL EQUIPMENT AND STTPPT,TES Airway: 1C Fixed suction system with wide bore tubing, rigid pharyngeal curved suction tip and soft catheter suction tip with sizes from 5 Fr. to 14 Fr. ')(, Portable suction system with wide bore tubing, rigid pharyngeal curved suction tip and soft catheter suction tip with sizes from 5 Fr. to 14 Fr. Bulb Syringe, Nasopharyngeal airways in pediatric and adult sizes. Oropharyngeal airways in pediatric and adult sizes. ite stick or equivalent (otopharyngeal airway). Fixed oxygen system with a minimum storage capacity of 125 cubic feet (M cylinder) and a minimum delivery capability for three patients simultaneously at flows of at least 1-15 LPM. Portable oxygen system with a minimum storage capacity of 15 cubic feet (D cylinder) and a minimum delivery capability for one patient at flows of at least 1-15 LPM. K. Infant Bag -Valve -Mask with 500cc bag, reservoir and newborn, infant and child masks. )(N. Adult Bag -Valve -Mask with 1000cc bag, reservoir and adult mask. "All mask attachments must be 15mm" Y. Oxygen masks and cannulas capable of delivering oxygen to adults and infants at flows of at least 1-15 LPM. 1 PITKIN COUNTY BASIC LIFE SUPPORT REQUIRED EQUIPMENT LIST MEDICAL EQUIPMENT AND SUPP1 IES Diagnostic: 4. Blood pressure cuffs in large adult, regular adult, child;: infant and neonatal sizes. V Stethoscopes in adult and pediatric sizes. Pulse oximeter with adult and pediatric sensors. Immobilization & Splinting: y. One lower extremity traction splint. Upper and lower extremity splints of any type (vacuum, air, SAM, wire, board, etc.). Long spineboard, vacuum mattress or equivalent with appropriate accessories to immobilize patients from head to heels. X. One orthopedic stretcher (scoop). >< Short spineboard, KED or equivalent with appropriate straps to immobilize patients from head to pelvis. 7C Pediatric spineboard or adult spineboard adaptable to pediatric use. Adult and pediatric sized head immobilization equipment for each long spineboard and/or scoop stretcher carried. Rigid cervical immobilization collars in tall adult through infant sizes. Wound Care: Y. Bandages, including but not limited to, roller gauze, triangular and elastic per agency needs. Dressings, including but not limited to, trauma, ABD, gauze, occlusive and bandaids per agency needs. Sterile bum sheets. Povidone and alcohol swabs or equivalent. Adhesive tape, including but not limited to, 1" and 2" per agency needs. —7 Sterile irrigation solution. .vetrical Supplies: Sterile OB kit to include: towels, 4x4s, umbilical tape Or cord clamps, scissors, bulb syringe, sterile blanket and sterile gloves. 7N Silver Swaddler and stocking cap or equivalents. Inf_e�ction Control: It Exam gloves in small, medium and large sizes. Face and eye shields. •C Fluid -proof gowns with full length 'sleeves or equivalent. Y Disinfectant spray or wipes for personnel and equipment. Miscellaneous: x Oral glucose. 'C Activated charcoal. `t4 Heavy duty bandage scissors or shears capable of cutting clothing, belts, boots, etc. Kr. Spill -proof emesis container with at least I liter capacity. sic universal or separate male and female urinals. X Multi -level. wheeled gurney 7c Stair chair or equivalent. J y Blankets. )( Patient compartment heater. 2