HomeMy WebLinkAboutBocc Packet 12182013 Ambulance LicensesAGENDA ITEM SUMMARY
REGULAR MEETING DATE: December 18, 2013
AGENDA ITEM TITLE: 2014 Ambulance Licenses
STAFF RESPONSIBLE: Jim Richardson
ISSUE STATEMENT: Jim Richardson, Chairman of the Emergency Medical Trauma Advisory
Council, is requesting approval for annual ambulance licenses for 2014 for the following entities:
• Aspen Ambulance District: Medic 93, Medic 94, Medic 95, Medic 96
• Snowmass/Wildcat fire Protection District: Medic 71, Medic 72, Medic 73,
• Basalt/Rural Fire Protection District: Medic 41, Medic 42, Medic 43, Medic 44
BACKGROUND: The BOCC approved licenses for all these entities for 2013.
The completed applications for each of the three districts as approved by the respective service
directors and physician advisors are on file in the Clerk and Recorder's Office
RECOMMENDED BOCC ACTION: Approval of the 2014 Ambulance Licenses
PITKLV COUNTY
Ambulance Service Name_ kp2li AA -M l(,�t e
Service Area: ri irk
Full year X Partial year
Emergent X Transfer Special Event
Number of Ambulances Licensed: "1
Is this Service Licensed in other Locations? /V O
List Locations:
If other than Special Taxing District list Owners with Addresses and
Contact Information:
Physician Advisor: pa, l "' `o flIve Z
Address: 6 qD I Gz- 15tl e- CA eft( /L� r I%Pc-" GO D j� 1
Street/P.O. Box City State Zip
Contact Information: cf lU -� y -) 5'11 �y `� " 1 6_7s
Voice Fax E -Mail
Colorado Medical License Number: �J0 rlc7* 3
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 prosec tion.
Service Director's Signature: 2(� I �'
Date
Physician Advisor's Signature
Date
P,rrK'm couA Y
Application for Ambulance Permit
Service Information j
Service Namet4, {-? N A114
Address ,7 tc,£jM e L7v Z'
ee !
S(rcetll'.U. City State 'lip
Communication j�gq-1'JgI Gqq",519
Voice
Vehicle Information
Radio Call Sign M ct-f)
rar
F: -!Fail
License Plate
�-
VIN
Year �00 1 Make
6114 C
Where will Vehicle be Stationed 11 v Ij
Waiver Request (Include Reason for Request)
crvice Iiirector's Name
(Ambulance Inspector Use Only)
Valid Insurance Card Yes ( No ( ]
Valid Registration Card Yes (} No ( }
4X4 Yes (Srr No ( )
Type 1414A
Inspection Fee $50.00 ( ) Mechanical Condition Certificate Attached }
Required BLS Equipment List Attached
Required ALS Equipment List Attached
Pass inspection Fail( ) Reason for Failure
nspectur s ame�i nafurs a e
M ff/i Trim, "IN.2
Required Basic Life Support Equipment List
Inspector 5, e4 Date
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 G fr. through 14 fr.
} Bulb syringe.
XV
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.
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 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 15Enm 121mm
fittings in the following sizes;
M 504cc bag with transparent masks for infant and neonate.
750cc bag with transparent masks for children..
} 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
Blood pressure cuffs to include large adult, regular adult, child, infant, and
neonatal sizes.
Stethoscope in adult and pediatric sizes.
Penlight.
Pulse oximeter with adult and pediatric sensors.
7
Splinting Equipment
Lower extremity traction splint.
( Upper and lower extremity splints.
( Long board with 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.
Short board or equivalent, with the ability to immobilize the patient from head to
f 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
Bandages - various types and sizes per agency needs and Physician Advisor
protocol.
NA
y,) Multiple dressings (including occlusive dressings), various sizes per ambulance
service requirements, needs and Physician Advisor protocol.
Sterile burn sheets.
Alcohol swabs or equivalent.
j Adhesive tape, per ambulance service requirements, needs, and Physician Advisor
protocol.
( 9 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.
} 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.
Ambulance Service Medical Treatment Protocols.
I W Oral glucose.
1 Spill proof emesis container.
Universal and/or separate male / female urinals.
Stair Chair
3
Communications Equipment
�C} 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
0 medical control facility or a physician
N receiving facilities
[15 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.
(\/j` 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
A set of three (3) warning reflectors.
One (1) ten pound (10 lb.) or two (2) five pound (5 1b.) 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 lfl
section 4.
MChild safety seat or equivalent
{ Appropriate protective restraints for patients, crew, accompanying family
members, and other vehicle occupants.
Properly secured patient transport system (i.e. wheeled stretcher).
j(} Triage tags as approved by the Colorado Department of Public Health and
Environment.
(4_ Restraining devices for all items not in a securable cabinet.
} Two "NO SMOKING -OXYGEN IN LSF" signs, one in cab, one in patient
compartment.
Reflective vests, coat or equivalent for each member of the crew normally
assigned.
PFFKIN COUNTY
Required Advanced Life Support Equipment List
Inspector S, /fin4�w�. Date 1 -j
Vehicle Radio Call Sign M — 4
Minimum Equipment Requirement for Advanced Life Support Ambulances
(V5 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 Physician Advisor protocol.
(� Laryngoscope and blades, straight, and/or curved of sizes 0-4.
(� Adult and pediatric magill forceps.
(J) End tidal CO2 detector or alternative device, approved by the FDA, for
determining correct tube placement.
Patient Assessment Equipment
(li Portable, battery operated cardiac monitor- defibrillator with strip chart recorder
and adult and pediatric EKG electrodes and defibrillation capabilities.
(4 Electronic blood glucose measuring device.
Intravenous Equipment
(� Adult and pediatric intravenous solutions and administration equipment per
Physician Advisor protocol.
(JS 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 A14 D , 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.
vC�'I�JGLSU�✓ �/�� �y� l�3
Service Director's Name
Date
PITKM COUNTY
Vehicle Safety and Operability Certification
Ambulance Service Aspen Ambulance District
Vehicle Radio Call Sign Medic 93
System Acceptable Non Acceptable Comment_
Tires { (�
Wheels (✓s �]
Alignment
Suspension
Brake System { 1
Parking Brake {VJ { }
Headlip-hts
Sto 1Turn/Brake Lts.
Visual Warning Lights Wr �}
Audible Warning elf ( )
Electrical System ( ( ]
Exhaust System
Fuel System
Glass/Mirrors LZ {�
Body & Sheet Metal (�j { }
General Present Condition, Excellent (►< Good ( ) Moderate ( ) Poor( )
Mileage when Inspected 11
I, Matt Bergstresser _ , professing to be a
motor vehicle technician with training in the systems listed above, have evaluated the
condition of all systems and have found thein to be in a safe and working condition.
Signature
970-920-5393
Phone
VJ11cler 111"P%iCllwl
PIrKiN COUNTY
76 Service Center Dr
Address
Agcncy/Company
11-19-2013
Date
T'IT'I m couA TTY
Application for Ambulance Permit
Service Informati�o}n
Service Name
Address U i Cct Gj2 C2Q A�n C U 9/6//
5treetl11.0. City State Zip
Communication y-1o�61y-1�'79
Voice
Vehicle Information
Radio Call Sign
P\J�C�q
Fax
M -Mail
License Plate 9S 3 — (72w
VIN I TUGclk�� 4X4 Yes No { }
Year Make!�?•� _ Type
Where will Vehicle be Stationed q V H
Waiver Request (Include Reason for Request)
ime5
Service Dire[
nature
(Ainhulance Inspector Use Only)
Valid Insurance Card Yes No { )
Valid Registration Card Yes ( No ( }
PJM
Inspection Fee S50.00 ( ) Mechanical Condition Certificate Attaclied`k'o
Required BLS Equipment List Attached}
Required ALS Equipment List Attached
Pass Inspection 6 Fail (} Reason for Failure
ND
1
PrrKLv couN7'Y
Required Basic Life Support Equipment List
Inspector 13 C ofd- N4 � �vk.r Date O rPAS_ i3
Vehicle Radio Call Sign I\A '� 14
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 G 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.
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 15min 121 mm
fittings in the following sizes;
N 500cc bag with transparent masks for infant and neonate.
�`�C} 750cc bag with transparent masks for children.
1000cc bag with transparent masks for adult.
{ Nasopharyngeal airways in pediatric and adult sizes 12 fr. through 32 fr.
�C}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.
Penlight.
Pulse oximeter with adult and pediatric sensors.
Splinting Equipment
Lower extremity traction splint.
Upper and lower extremity splints.
Q Long board with equipment to immobilize the patient from head to heels.
9-� 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.
( 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
'} 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.
N Sterile burn sheets.
YAlcohol swabs or equivalent.
(.A Adhesive tape, per ambulance service requirements, needs, and Physician Advisor
protocol.
(g 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.
Neonate stocking cap or equivalent.
Miscellaneous Equipment
Heavy bandage scissors, shears or equivalent capable of cutting clothing, belts,
boots, etc.
Two working flashlights.
Q�. Blankets and appropriate heat source for the ambulance patient compartment.
( Ambulance Service Medical Treatment Protocols.
Oral glucose.
Spill proof emesis container.
( Universal and/or separate male 1 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:
ambulance service's dispatch
medical control facility or a physician
receiving facilities
} mutual aid agencies.
Body Substance Isolation Properly Sized To Fit All Personnel To Include;
Ql� 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.
(`F Disinfectant spray or wipes for personnel and equipment.
([V Sharps containers for the appropriate disposal and storage of medical waste and
biohazards.
�C) Particulate respirator, N95 type or better.
Safety Equipment
K A set of three (3) warning reflectors.
~- n 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.
Child safety seat or equivalent
Appropriate protective restraints for patients, crew, accompanying family
members, and other vehicle occupants_
} Properly secured patient transport system (i.e. wheeled stretcher).
Triage tags as approved by the Colorado Department of Public Health and
Environment.
Restraining devices for all items not in a securable cabinet.
.j Two "NO SMQKING-OXYGEN IN USE" signs, one in cab, one in patient
compartment.
XReflective vests, coat or equivalent for each member of the crew normally
assigned.
PFFJr COUJV7 Y
Vehicle Safety and Operability Certification
Ambulance Service Aspen Ambulance District
Vehicle Radio Call Sign Medic 94
System Acceptable Non Acceptable Comment
Tires (tom ( )
Wheels (c.Y ( )
Alignment (61)e' ( )
Suspension Wy ( )
Brake System (L-' ( )
Parking Brake (4-K ( )
Headlights (� l )
Stop/Turn/Brake Lts. (� ( )
Visual Warning Lights (-� ( }
Audible Warning (tL ( )
Electrical System (JIB _� )
Exhaust System ( kY ( )
Fuel System ('-Y1 ( )
Glass/Mirrors
Body & Sheet Metal
General Present Condition, Excellent (y< Good( Moderate () Poor( }
Mileage when Inspected
I, � C in PS [it 4 w� , 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.
Ql,—,
4W , YAj���� ti ����'flv
Phone
S A0 �- �(p SPr fjr c e Ce0ol eo-,
Address
Date
/i113112
This evaluation will not guarantee future safety and or operability of this ambulance
due to conditions beyond the technician's control.
V4hicle 1Fi-;hc':1!iW
PFFKM COUNTY
Required Advanced Life Support Equipment List
Inspector 5, AA J4 -,t^- Date 11 Zy 13.
Vehicle Radio Call Sign /M -7q
Minimum Equipment Requirement for Advanced Life Support Ambulances
(%4 All Equipment Listed In BLS Equipment list
Ventilation Equipment
(Vf 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.
(V Laryngoscope and blades, straight, and/or curved of sizes 0-4.
{ y 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
(� Portable, battery operated cardiac monitor- defibrillator with strip chart recorder
and adult and pediatric EKG electrodes and defibrillation capabilities.
(11� Electronic blood glucose measuring device.
Intravenous Equipment
(d Adult and pediatric intravenous solutions and administration equipment per
Physician Advisor protocol.
(V� Adult and pediatric intravenous arm boards.
Pharmacological Agents
(Vj Pharmacological agents and delivery devices per Physician Advisor protocol.
(J� Pediatric "length based" device for sizing drug dosage calculations and sizing
equipment.
As Service Director for � 140. , 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.
J4eAU-5; gs'CG444a-.l
Service Director's Name
mac/
Date
PITKIN COUl TY
Application for Ambulance Permit
Service Information nn �J
Service Name L20e lv A111l &—A f!! &--.JC L'
'F ,p
AddressA U t � S fk �zeG` / �I ld , 'e --V l 6o C� 1(J ( r
StrectlY.0.' City State Zip
Communication 5`fq} 7-7 1 --Jgq-1Wv
Voice
Vehicle Information
Fa r
E -Mail
Radio Call Sign License Plate y q ` N L�
VIN (7 V 3"i lb � � � Pq � g o 1 4X4 Yes ¢-r No ( )
Year 7 V U
Make 61�1G
Where will Vehicle be Stationed A V +.
Waiver Request (Include Reason for Request)
Service director's
re
(Ambulance Inspector Use only)
Valid Insurance Card Yes o No ( )
Valid Registration Card Yespl, No ( )
IN
Type 4114 6G y 1'k
/z1/ //-3
Inspection Fee S50.00 ( ) Mechanical Condition Certificate Attached`6
Required BLS Equipment List Attached
Required ALS Equipment List Attached
Pass Inspection Fail.( ) Reason for failure
1}ate
T speTr s-i�mc---------�ignaturc—_— "7f �r —
PFF flV CCUM Y
Required Basic Life Support Equipment List
Inspector 17 c o—H Ar 11'v " Date i — ? i }j
Vehicle Radio Call Sign Mei 5
Minimum Equipment Required for Basic Life Support Ambulance
Ventilation Equipment
{t� 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.
(tr� Bulb syringe.
(L 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.
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 121 mm
fittings in the following sizes;
500cc bag with transparent masks for infant and neonate.
750cc bag with transparent masks for children.
(L� 1000cc bag with transparent masks for adult.
Nasopharyngeal airways in pediatric and adult sizes 12 fr. through 32 fr.
(L-r� Oropharyngeal airways in adult and pediatric sizes to include: infant, child, small
adult, adult and large adult.
Patient Assessment Equipment
(t-) Blood pressure cuffs to include Iarge adult, regular adult, child, infant, and
neonatal sizes.
Stethoscope in adult and pediatric sizes.
Penlight.
( Pulse oximeter with adult and pediatric sensors.
7
Splinting Equipment
( Lower extremity traction splint.
[ Upper and lower extremity splints.
Long board with 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.
(�) 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 Bead immobilization equipment.
Dressing Materials
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.
(•� Alcohol swabs or equivalent.
} Adhesive tape, per ambulance service requirements, needs, and Physician Advisor
protocol.
Sterile irrigation solution.
Obstetrical Supplies
(L} 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.
} Two working flashlights.
} Blankets and appropriate heat source for the ambulance patient compartment.
Ambulance Service Medical Treatment Protocols.
( Oral glucose.
Spill proof emesis container.
911, Universal and/or separate male 1 female urinals.
M 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:
ambulance service's dispatch
} medical control facility or a physician
( receiving facilities
mutual aid agencies.
Body Substance Isolation Properly Sized To Fit All Personnel To Include;
NANon-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.
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
KA set of three (3) warning reflectors.
One (1) ten pound (10 lb.) or two (2) rive 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.
UQ Child safety seat or equivalent
Appropriate protective restraints for patients, crew, accompanying family
members, and other vehicle occupants.
` Properly secured patient transport system (i.e. wheeled stretcher).
Triage tags as approved by the Colorado Department of Public Health and
Environment.
Restraining devices for all items not in a securable cabinet.
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.
PFFKH COUNTY
Vehicle Safety and Operability Certification
Ambulance Service Aspen Ambulance District
Vehicle Radio Call Sign Medic 95_
System Acceptable Non Acceptable Comment
Tires
Wheels
Alignment
Suspension oA ( )
Brake System M (_)
Parking Brake M {�
Headlights M { )
Stop/Turn/Brake Lts. (0 ( )
Visual Warning Lights (pd { )
Audible Warning (y) ( )
Electrical System (VS ( )
Exhaust System
Fuel System M ( )
Glass/Mirrors M { )
Body & Sheet Metal 06 ( )
General Present Condition, Excellent) Good( Moderate () Poor( )
Mileage when Inspected
I, 9ySktQsW , 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.
Signature
Agency/Company
,Jn- �- ca - 5r�q f� 7 (a cet icti- A(L it kri 2(31�
Phone Address Date
This evaluation will not guarantee future safety and or operability of this ambulance
due to conditions beyond the technician's control.
V'A"icle In"PCC110n
;a,
Pzmm COUNTY
Required Advanced Life Support Equipment List
Inspector Date (k!513
Vehicle Radio Call Sign - S
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 Physician Advisor protocol.
() 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
() 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.
() 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 1 41) , 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.
Service Director's Name
Date
P.rrKL?v CoUATY
Application for Ambulance Permit
Service Name --- ---�-n 1"'x+6-1" 1C-1JC-- I005
Address O qU C�'I� G�P�.�i�! [� 9/b
StreetT.O. City SIatc Zip
Communication 5q q- 1 1 G y y-1 SgL>
Voice
Vehicle Information
Radio Call Sign
oql�
Fax
E -Mail
License Plate q �J -- t1 Ui-
VIN l FDw l✓ 3-7 rL.7-%C1—�:' �5j55'I
Year �7 ou
4X4 Yes*f No ( )
Make s-�� Type ,4-t
Where will Vehicle he Stationed 40 4
Waiver Request (Include Reason for Request)
e
Service nireei
(Ain Itulancc Inspector Use On 1y)
Valid Insurance Card Yes -0 No ( )
Valid Registration Card Yes r) No ( )
Inspection Fee $50.00 ( ) Mechanical Condition Certificate Attached QCS
Required BLS Equipment List Attached
Required ALS Equipment List Attached { }
Inspection W Fail( ) Reason for Failure
a5V"r\ Ctnq nl_ V,\ "h CeV
1 zh
�ii inspector s ame
1
PFFK V COUNTY
Required Basic Life Support Equipment List
Inspector SC c* A-f(\.cam
Vehicle Radio Call Sign
]vA '� la
Date kk-Dt)- C3
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 G 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.
tl� Portable oxygen system with a minimum storage capacity of 15 c.f.. (D cylinder)
and a niinimum delivery capability for 1 -patient at flows of least I-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 121mm
fittings in the following sizes;
(�- 500cc bag with transparent masks for infant and neonate.
{�c} 750cc bag with transparent masks for children.
10 00c bag with transparent masks for adult.
Nasopharyngeal airways in pediatric and adult sizes 12 fr. through 32 fr.
Ak
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, ini'ant, and
Y" neonatal sizes.
Stethoscope in adult and pediatric sizes.
() Penlight.
Pulse oximeter with adult and pediatric sensors.
9
Splinting Equipment
Lower extremity traction splint.
YIIIA
K Upper and lower extremity splints.
rF 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.
( 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
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.
i Alcohol swabs or equivalent.
Adhesive tape, per ambulance service requirements, needs, and Physician Advisor
protocol.
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.
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 coinpartment.
Ambulance Service Medical Treatment Protocols.
¢Q Oral glucose.
Spill proof emesis container.
Q Universal and/or separate male 1 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:
} ambulance service's dispatch
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.
&A 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.
11114
Particulate respirator, N95 type or better.
Safety Equipment
A set of three (3) warning reflectors.
One (1) ten pound (14 lb.) or two (2) rive 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
1K Appropriate protective restraints for patients, crew, accompanying family
members, and other vehicle occupants.
Properly secured patient transport system (i.e. wheeled stretcher).
Triage tags as approved by the Colorado Department of Public Health and
Environment.
Restraining devices for all items not in a securable cabinet.
yQ 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.
Pl l .�ilL ■ co r TY
Vehicle Safety and Operability Certification
Ambulance Service Aspen Ambulance District
Vehicle Radio Call Sign Medic 96
System Acceptable Non Acceptable Comment
Tires.-
Wheels--
Ali;nment 00
Suspension W {_}
Brake System (00
Parking Brake
Headlights {) { }
Stop/Turn/Brake Us.
Visual Warning Lights fyj { )
Audible Warning-- _ - (x] �}
Electrical System W { }
Exhaust System N) { )
Fuel System 04) ( )
Glass/Mirrors fix} _ L)
Body & Sheet Metal 00 {
General Present Condition, Excellent (N Good( Moderate (} Poor { }
Mileage when inspected �2 �t ,3
I,U JG,rP.I&Lr , professing to be a motor vehicle
technician wi t14 training in the systems fisted above, have evaluated the condition of all
systems and have found them to be in a safe and working condition.
YfOl—, - pleJ
Signature Agency/Corn4ly
Phone Address
-7'7 a t�
PFFKLV COUNTY
Required Advanced Life Support Equipment List
Inspector) Date
Vehicle Radio Call Sign - 9�
Minimum Equipment Requirement for Advanced Life Support Ambulances
(,41 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 Physician Advisor protocol.
4 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
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.
(� Adult and pediatric intravenous arm boards.
Pharmacological Agents
(4 Pharmacological agents and delivery devices per Physician Advisor protocol.
4 Pediatric "length based" device for sizing drug dosage calculations and sizing
equipment.
As Service Director for AM. , 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.
�ILI/l�r G�S�n-� C / ��li✓
Director's Name )Signature
11z � r3.
Date
PAIR COUJV7 Y
Ambulance Service Name: Snowmass-Wildcat Fire Protection District
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 City State Zip
Contact Information: 970-922-6000 same gbalkornd@gmail.com
Voice Fax F.-MAH
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 prosecutio' .
Service Director's Signature:
nate
111iysician Advisor's Signature
Datc
A f toNontXe rmit
PP li
Service Information
Service Name: Snowmass-Wildcat Fire Protection District
Address: PD Box 6436 Snowmass Villa e co 81615
Street/P.Q. City State 'Lip
Communication: 970-923-2212 970-923-2224 sarthur sw d.com
Voice Fax E -Mail
Vehicle Information
Radio Call Sign: M71
VIN: 1 FDWF37PX5ED 13429
Year: 2005
License Plate: 447 HVJ
4X4 Yes (X) No ( )
Make: Ford Type: 1
Where will Vehicle be Stationed:_ 5275 Owl Creek Road, Snowmass Village, CO
Waiver Request (Include Reason for Request)
John Mete
ce Director's Name
tire
(Ambulance Inspector Use Only)
Valid Insurance Card Yes K No { )
Valid Registration Card Yes No { )
Inspection Fee $50.00 0— Mechanical Condition Certificate Attached (/
Required SLS Equipment List Attached K
Required ALS Equipment List Attached W
P nspectr ( ) Fail ( ) Reason for- failure
_P. iy. 14
Inspector's Name
Date
rJ
1
PFFKL VV U1t l l
Vehicle Safety and Operability Certification
Ambulance Service Snow mass-Wildcat Fire Protection District
Vehicle Radio Call Sign l
system Acceptable Non Acceptable Comment
Tires fa
Wheels
Alignment
Suspension
Brake System
Parkiniz Brake
Headlights ( ( }
Stop/Tum/Brake Lts. N (_}
Visual Warning Ligbts (4) ( }
Audible Warning__ _ (�
Electrical System4
Exhaust System 6Q (^}
Fuel System 1
Glass/Mirrors
Body & Sheet Metal
General Present Condition Excellent (} Good } Moderate { } Poor ( }
Mileage when Inspected Z
1, ALI , professing to be a motor vehicle
technician with training in the systems listed above, have evaluated the condition of all
systeVandound them to be in a safe and working condition.
I.
Signature Agency/Company
- z rel fJ 004 Lin- � 3
Phone Address Date
This evaluation will not guarantee future safety and or operability of this ambulance
due to conditions beyond the technician's control.
PFFKLR CO UJ V 7 Y
Required Basic Life Support Equipment List
Inspector , /7 Xr Date 1 Z r i7
Vehicle Radio Call SJkn 7
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 sots catheter suction
tips to include pediatric sizes 6 fr. through 14 fr.
(p� Bulb syringe.
House oxygen with 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.
(p Portable oxygen system with a minimum delivery capability for 1 patient at flows
of least 1-15 L.P.M.
(Ip( 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.
I 000cc bag with transparent masks for adult.
( Nasopharyngeal airways in adult sizes 24 fr. through 32 fr.
(� 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 and infant sizes.
(p� Stethoscope in adult size.
k-4 Penlight.
Splinting Equipment
(v Lower extremity traction splint.
(� Upper and lower extremity splints.
(v(� Long board with equipment to immobilize the patient from head to heels.
131 '� I-"CxluII-cd I (yuII)III CuI
2
PL Scoop, vacuum mattress or equivalent, with appropriate accessories to immobilize
The patient from head to heels.
(p� Short board or equivalent, with the ability to immobilize the patient from head to
pelvis.
(p� Pediatric immobilization device or adult immobilization device that can be
adapted for pediatric use.
(Q Adult and pediatric cervical spine and head immobilization equipment.
Dressing Materials
P4 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.
k,j., Sterile burn sheets.
Adhesive tape, per ambulance service requirements, needs, and Physician Advisor
protocol.
( 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.
K, Neonate stocking cap or equivalent.
Miscellaneous Equipment
Heavy bandage scissors, shears or equivalent capable of cutting clothing, belts,
boots, etc.
Two working flashlights.
(p Blankets and appropriate heat source for the ambulance patient compartment.
(p Ambulance Service Medical Treatment Protocols.
(0 Oral glucose.
(A Stair Chair
Communications Equipment
(K All communications equipment shall be maintained in good working order. The
communications equipment must be capable of transmitting and receiving clear
voice communications.
lil,ti IZCLI IIII d IAI(III)n)CIII
3
Two-way communications that will enable the ambulance personnel to communicate
with:
ambulance service's dispatch
(p� 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 I box of latex free gloves.
,(-A Protective eyewear.
f Non-sterile surgical masks.
Disinfectant spray or wipes for personnel and equipment.
(p� Sharps containers for the appropriate disposal and storage of medical waste and
biohazards.
(.4 Particulate respirator, N95 type or better.
Safety Equipment
(�( A set of three (3) warning reflectors.
( 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.
(o4 Child safety seat or equivalent
Appropriate protective restraints for patients, crew, accompanying family
members, and other vehicle occupants.
Properly secured patient transport system (i.e. wheeled stretcher).
Triage tags as approved by the Colorado Department of Public Health and
Environment.
Restraining devices for all items not in a securable cabinet.
( 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.
HI '�, RC(IIIIICtI hILIII)IIICIIt
Pl L I,lL■ VVVjw.[
RequiredAdvanced Life Support Equipment List
Inspector (;11/4w11--A,Date 44L/ Z
Vehicle Radio Call Si /x7
Minimum Equipment Requirement for Advanced Life Support Ambulances
96 All Equipment Listed In BLS Equipment list
Ventilation Equipment
gyp{ 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 5.0-8.0 per Physician Advisor protocol.
Laryngoscope and blades. straight, and/or curved of sizes 0-4.
j Adult and pediatric magill forceps.
(may End tidal CO2 detector or alternative device, approved by the FDA, for
determining correct tube placement.
Patient Assessment Equipment
{p} Portable, battery operated cardiac monitor- defibrillator with strip chart recorder
and adult and pediatric EKG electrodes and defibrillation capabilities.
{04 Pulse oximeter with adult and pediatric sensors.
(pd Electronic blood glucose measuring device.
Intravenous Equipment
Adult and pediatric intravenous solutions and administration equipment per
Physician Advisor protocol.
(A� Adult and pediatric intravenous arm boards.
Pharmacological Agents
[00- Pharmacological agents and delivery devices per Physician Advisor protocol.
O�L 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.
John Mete
Service Director's Name
Date
Applif tiol7 �19qu1 .trice lerniit
Service Information
Service Name: Snowmass-Wildcat Fire Protection District
Address: PO Box 6436 Snowmass Village CO 81615
StrectlP.O. City State Zip
Communication: 970-923-2212 970-923-2224 sarthur sw d.com
Voice Fax E -Mail
Vehicle Information
Radio Call Sign: M72
VIN: I FDUF4HT5CE850579
License Plate: 887 GPW
4X4 Yes (X) No ( )
Year: 2012 Make: Ford Type: I
Where will Vehicle be Stationed: 5275 Owl Creek Road, Snowmass Village, CO
Waiver Request (Include Reason for Request)
John Mele
re Director's Nam
(Ambulance Inspector Use only)
Valid Insurance Card Yes (p6 No { }
Valid Registration Card Yes K No ( )
Inspection Fee SSU -00 04 Mechanical Condition Certificate Attached yCj
Required BLS Equipment List Attached ( )
Required ALS Equipment List Attached ( )
ass Inspection ) Fail( ) Reason for li ai! a re
1
PFFKfN COUN Y
Required Advanced Life Support Equipment List
Inspector C Date /21.7
Vehicle Radio Call Sig h %Z
Minimum Equipment Requirement for Advanced Life Support Ambulances
{ <, All Equipment Listed In SLS 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 Physician Advisor protocol.
(QCj_ Laryngoscope and blades, straight, and/or curved of sixes 0-4.
j?Q Adult and pediatric magill forceps.
End tidal C07 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.
Pulse oximeter with adult and pediatric sensors_
Electronic blood glucose measuring device.
Intravenous Equipment
Adult and pediatric intravenous solutions and administration equipment per
Physician Advisor protocol.
(P} Adult and pediatric intravenous arm boards.
Pharmacological Agents
K Pharmacological agents and delivery devices per Physician Advisor protocol.
t4 Pediatric "lengh 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.
John Mele
Service Director's Name Sijnature Date
11 lzc• IIII 1-cii f :I!IiI,!iwro
PrrK cou l
Vehicle Safety and Operability Certification
Ambulance Service Snowmass-Widcat Fire Protection District
Vehicle Radio Call Sign
Svstem Acceptable Non Acceptable Comment
Tires - 13 z- A 1313
W heels
Parking Brake W �}
Headlights V) J, _}
Sto ITum/Brake Lts.
Visual Warninu Lights
Audible Warnina N1 f )
Electrical S
Exhaust System (k} { }
Fuel System CK} { }
Glass/Mirrors k} L}
Body & Sheet Metal [k} ( }
General Present Condition Excellent Good( Moderate () Poor( }
Mileage when Inspected�� 9 ��
I, X rt. �1�l ,, professing to be a motor vehicle
technician with gaining in the systems listed above, have evaluated the condition of all
systems and ha)�p fob them. to be in a safe and working condition.
1 �L� ':4eel 144r7
Signature Agency/Company
I l r i S
LILO
Phone
Address
Date
This evaluation will not guarantee future safety and or operability of this ambulance
due to conditions beyond the technician's control.
J
PITT mCOl1 7Y
Required Basic Life Support Equipment List
Inspector C t Date
Vehicle Radio Call Sign 7Z
Minimum Equipment Required for Basic Life Support Ambulance
Ventilation Equipment
(t4 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.
(lj House oxygen with 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.
(04 Portable oxygen system with 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 / 21mm
fittings in the following sizes;
{04 500cc bag with transparent masks for infant and neonate.
(Id 750cc bag with transparent masks for children.
(0 1 000c bag with transparent masks for adult.
( Nasopharyngeal airways in adult sizes 24 fr. through 32 fr.
(go Oropharyngeal airways in adult and pediatric sizes to include: infant, child, small
adult, adult and large adult.
Patient Assessment Equipment
04 Blood pressure cuffs to include large adult, regular adult, child and infant sizes.
(l( Stethoscope in adult size.
K Penlight.
Splinting Equipment
(1x Lower extremity traction splint.
Upper and lower extremity splints.
(p� Long board with equipment to immobilize the patient from head to heels.
Iil S KCk{1111Cd I
2
Scoop, vacuum mattress or equivalent, with appropriate accessories to immobilize
The patient from head to heels.
(0Q Short board or equivalent, with the ability to immobilize the patient from head to
pelvis.
(Q Pediatric immobilization device or adult immobilization device that can be
adapted for pediatric use.
(0d Adult and pediatric cervical spine and head immobilization equipment.
Dressing Materials
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.
fps Sterile burn sheets.
{� Adhesive tape, per ambulance service requirements, needs, and Physician Advisor
protocol.
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.
kQ Neonate stocking cap or equivalent.
Miscellaneous Equipment
(04_ Heavy bandage scissors, shears or equivalent capable of cutting clothing, belts,
boots, etc.
Two working flashlights.
(p Blankets and appropriate heat source for the ambulance patient compartment.
�j Ambulance Service Medical Treatment Protocols.
Oral glucose.
Stair Chair
Communications Equipment
LA All communications equipment shall be maintained in good working order. The
communications equipment must be capable of transmitting and receiving clear
voice communications.
IiI,") RCtluirCxl IAILIIhmCnt
3
Two-way communications that will enable the ambulance personnel to communicate
with:
(od ambulance service's dispatch
(p6 medical control facility or a physician
04 receiving facilities
00 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.
(v Protective eyewear.
Non-sterile surgical masks.
(Q Disinfectant spray or wipes for personnel and equipment.
(/4 Sharps containers for the appropriate disposal and storage of medical waste and
biohazards.
( Particulate respirator, N95 type or better.
Safety Equipment
A set of three (3) warning reflectors.
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.
Child safety seat or equivalent
( Appropriate protective restraints for patients, crew, accompanying family
members, and other vehicle occupants.
(off Properly secured patient transport system (i.e. wheeled stretcher).
Triage tags as approved by the Colorado Department of Public Health and
Environment.
(� Restraining devices for all items not in a securable cabinet.
�j 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.
I i I ti ILC(ILIiI-0I I (It il) InCnt
F17 W
APP lif ioo or AIMWancXermit
Service Information
Service Name: Snowmass-Wildeat Fire Protection District
Address: PO Box 6436 Snowmass Village CO 81615
Street/P.O. City State 'Lip
Communication: 970-923-2212 970-923-2224 sarthur(d7swfpd.com
Voice Fax E -Mail
Vehicle Information
Radio Call Sign: M73 License Plate: 789 VKA
VIN: 1FDAF4HR3AE839794 4X4 Yes (X) No ( )
Year: 2010
Make: Ford Type: I
Where will Vehicle be Stationed: 5275 Owl Creek Road, Snowmass Village, CD
Waiver Request (Include Reason for Request)
John Mele
ature
F_
(Ambulance Inspector Use only)
Valid Insurance Card Yes 04 No { }
Valid Registration Card Yes (4 No { }
Inspection. Fee $50.00 K Mechanical Condition Certificate Attached A
Required BLS Equipment List Attached 04 -
Required ALS Equipment List Attached (P�-_
EInspection ) Fail( ) Reason for Failure
V. M
Inspector's Nam
Si
ate
rVZ7
1
MM0 t' it 1
Vehicle Safety and Operability Certification
Ambulance Service Snow mass -Wildcat Fire Protection District
Vehicle Radio Call Sign M'7_:�
System Acceptable Non Acceptable Comme
Tires YI) (- q I
Wheels
Alignment
Brake System VA .---k
Parking Brake
Headlights
Stop/Turn/Brake_Lts. N ( j
Visual Warning Lights {]Q [ }
Audible Warning (�
Electrical System} }
Exhaust System 11til,1Cr- I k
Fuel System
Glass/Mirrors { ]
Body & Sheet Metal
General Present Condition Excellent tA Good {) Moderate( Poor ( }
Mileage when Inspected 1 T q
I, Le- professing to he a motor vehicle
technician with trai ing in the systems listed above, have evaluated the condition of all
systej� anal haveund them to be in a safe and working condition.
--<,r I el
Signature Agency/Company
Phone
c--9 Z ,1 L 6a, it, m y Z LA a
Address
Date
This evaluation will not guarantee fixture safety and or operability of this ambulance
due to conditions beyond the technician's control.
I ?A -
PFFK COUAT7Y
Required Basic Life Support Equipment List
Inspector . �� Date !2 !'
Vehicle Radio Call Agn 7-Y
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.
Bulb syringe.
House oxygen with 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.
f Portable oxygen system with 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 / 21mm.
fittings in the following sizes;
PO 500cc bag with transparent masks for infant and neonate.
kO 750cc bag with transparent masks for children.
(4 1 000c bag with transparent masks for adult.
(k Nasopharyngeal airways in adult sizes 24 fr. through 32 fr.
(po- 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 and infant sizes.
Stethoscope in adult size.
K Penlight.
Splinting Equipment
(p' Lower extremity traction splint.
(Pq_ Upper and lower extremity splints.
K Long board with equipment to immobilize the patient from head to heels.
ISI RC(It IIIC,I I (lull) i iI:nt
a
(et� 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.
(.� Pediatric immobilization device or adult immobilization device that can be
adapted for pediatric use.
�j Adult and pediatric cervical spine and head immobilization equipment.
Dressing Materials
f 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.
(4 Sterile burn sheets.
( Adhesive tape, per ambulance service requirements, needs, and Physician Advisor
protocol.
(p� 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.
( 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.
(Do- Ambulance Service Medical Treatment Protocols.
{ Oral glucose.
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.
I;L RCtItIIrC<I I-:yuilm]cIit
M
Two-way communications that will enable the ambulance personnel to communicate
with:
(k ambulance service's dispatch
J4 medical control facility or a physician
00 receiving facilities
mutual aid agencies.
Body Substance Isolation Properly Sized To Fit All Personnel To Include;
(Pd Non-sterile disposable gloves in small, medium, and large sizes, to include a
minimum 1 box of latex free gloves.
(4 Protective eyewear.
(p Non-sterile surgical masks.
fps Disinfectant spray or wipes for personnel and equipment.
Sharps containers for the appropriate disposal and storage of medical waste and
biohazards.
K Particulate respirator, N95 type or better.
Safety Equipment
(M A set of three (3) warning reflectors.
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.
Child safety seat or equivalent
(off Appropriate protective restraints for patients, crew, accompanying family
members, and other vehicle occupants.
(p4 Properly secured patient transport system (i.e. wheeled stretcher).
Triage tags as approved by the Colorado Department of Public Health and
Environment.
(e� Restraining devices for all items not in a securable cabinet.
(� 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.
I;I,'N' RC(IIIirrcl I�(ILIihmont
PFFKM SOU
RequiredlAdvanced Life Support Equipment List
Inspector
�W,, �-- Date I /S
J
Vehicle Radio Call Sign /y-72
Minimum Equipment Requirement for Advanced Life Support Ambulances
(K 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 Physician Advisor protocol.
(rte Laryngoscope and blades, straight, and/or curved of sizes 0-4.
(p6 Adult and pediatric magill forceps.
(p4- End tidal CO-, detector or alternative device, approved by the FDA, for
determining correct tube placement.
Patient Assessment Equipment
(t4 Portable, battery operated cardiac monitor- defibrillator with strip chart recorder
and adult and pediatric EKG electrodes and defibrillation capabilities.
{ Pulse oximeter with adult and pediatric sensors.
{ Electronic blood glucose measuring device.
Intravenous Equipment
) Adult and pediatric intravenous solutions and administration equipment per
Physician Advisor protocol.
(PCS Adult and pediatric intravenous arm boards.
Pharmacological Agents
,j 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 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.
John Mete
Service Director's Name
Signature
r
Date
f2
Applif iooNoWrr Aqb� nl�Xe r m i t
Service Information
Service Name: {3p SAL:f if RU'f—►4L"FO-V- P-+oTB7C- " O i( taISM% Lr
Address: logc) -jw DRl YF -7
street/P.O.
Communication:
Voice
Vehicle Information
CIf,Afz-OON OPIVE G0
City State
q -ley --10'A —Ob 2's
fax
Radio Call Sign: M H ( License Plate:_t3 F
VIN: 4X4 Yes (X) No ( )
iFt wFyIt^p6FQms-3
Year: 2, cs is 6 Make: r -v F4,A Type:- J
Where will Vehicle be Stationed: s ono tv Li i
Waiver Request (Include Reason for Request)
E)16 -L-3
Zip
PC,at—n#,?ji� �4JgSIth-ft`fL�c�t^t
E -Buil
g1e—H TARN CotZNi L1ucS AZ- -01� R 1Z6cil l3
Service Director's Name Signature Date
(Ambulance Inspector Use Only)
Valid Insurance Card Yes No ( )
Valid Registration Card Yes No ( )
Inspection Fee $50.00N Mechanical Condition Certificate Attachcd'�Q
Required BLS Equipment List Attached
Required ALS Equipment List Attached}
Pass Inspection p Fail ( ) Reason for Failure
Inspector's Name
Signature
Vs- 1113
Date
1
Pm riN c® um Y
Vehicle Safety and Operability Certification
Ambulance Service e> � �
Vehicle Radio Call Sign N 1
System Acceptable Non Acceptable Comment
Tires
Wheels { { )
Alignment
Suspension ( )
Brake System
Parking Brake ( ( )
Headlights ( �}
Stop/Turn/Brake Lts. ( ( }
Visual Warning Lights
Audible Warning_(' (^}
Electrical System
Exhaust System (A� (�
Fuel System ( T
Glass/Mirrors
Body & Sheet Metal ( ( )
General Present Condition Excellent (\/f' Good( Moderate( Poor( )
Mileage when Inspected � 6) r k �
I, Amy ` Z C, t V--- , 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.
Signature Agency/Company
of -v AAS , c� , P, I6)-- % (13
Prone Address Date
This evaluation will not guarantee future safety and or operability of this ambulance
due to conditions beyond the technician's control.
1'k,E,1k 1k, In>I�(,k ,IIk,II
'!'\eip�c 41
COLORADO AUTO INSURANCE IDENTIFICATION CARD
WAPANY NANE, ADDRESS & NAIC NO.
At-UIRICAN ALTERNATIVE INSURAME CORPORATION
555 College Road East, Princeton, NJ 08543-5241
19720
an aulhorized Colorado Insurer has Lssued a poficy of sutomob7o Fabilly insurance provdfng coverage for bodily
injury, property damage Insurance in at least the minimum amounts prewbed by Colorado law, to:
WSUREO NAME & AIIDHFSS
BASALT AND RURAL FIRE PROTECTION
DISTRICT
1089 3W DRIVE
CRRBOyDALE, CO 81623-0000
POLICY NUMBER
VYISTR2061681
LwFfMCOLL
FORD Al-BULANCE ALS
INSURAXCE AC+NYIBROKER
VM
183 Leader 1Lelghts Road
York, PA 17405
(717) 741.9311
EFFECTIVE DATE EXPIRATION DATE
01-01-2013 01-01-2014
YEAR VEHICLE IDENTIFICATION NU%IBER
2006 1FLY,,IF37P06E D 67453
SEE REVERSE $0E UNIFORM R1321a (Ed. 7-031
rrnfnDAnn [7Ci-rc+ MAT
TYPE
.PLATE .. TABNAL '- I fA A 'VIN -'
PAS--CNY 078BHF
078BHF IFDWF31P06EtD"67453 PE
TITLE
YR MAKE BODY CWT11AS - T1 FLEETR PREY
44E514379
2006 FOR AM 119 4446
PUR. PATE
PUR. PRICE ORIGINAL TAXABLE VALUE S. DATE CO # UI
10/04/2006
127769.00 108,603 10/19/2006 44 R
EM. FEE
PRIOR O.T. OWN TAX L1C. FEE TITLE FEE OTHl f
0.00
0.00 0.00 3.26 7.20
RTD TAX
COUNTY TAX CITYIDIST TAX STATE TAX SPECIAL FEE
0.00
0.00 0,.00 0.00 0.00
UNITff
PILES H GVW Hr' marc
UWlvth NAMEIMAILING ADDRESS
BASALT AND RURAL FIRE
PROTECTION DISTRICT
1089 r7 W DR
CARBONDALE CO 81623
SIGNA:
REGUI
ON REN
SIDE,
VALrUA I IUN '
TOTAL
PAID EAGLE .01 1:0/19/2006 103047MKZ B03 Y 10.4'
MOTOR VEHICLE INSURANCE IS COMPULSORY IN COLORADO, NON-COMPLIANCE IS A MISDEMEANOR TRAFFIC 01
PrrxrlvCOUATY
Required Advanced Life Support Equipment List
Inspector E -'6? -t C ��_ 4N 5 � Date 102- d 1-�
Vehicle Radio Call Sign ("
Minimum Equipment Requirement for Advanced Life Support Ambulances
Y"' 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 -W- 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.
Adult and pediatric magill forceps.
End tidal CO2 detector or alternative device, approved by the FDA, for
determining correct tube placement.
Patient Assessment Equipment
19 Portable, battery operated cardiac monitor- defibrillator with strip chart recorder
and adult and pediatric EKG electrodes and defibrillation capabilities.
Pulse oximeter with adult and pediatric sensors.
Electronic blood glucose measuring device.
Intravenous Equipment
Adult and pediatric intravenous solutions and administration equipment per
Physician Advisor protocol.
Adult and pediatric intravenous arm boards.
Pharmacological Agents
M 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 Basalt and Rural 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.
F- U-11 11.11 tf3 f2 W LUL L -kr ii-._ L%.r .-,,l ru�.�e �w ..._. iS. i Ori 14 -Z.
Service Director's Name Signature Date
ALS Required Eguipinent
Prmm c4Ju d d
Required Basic Life Support Equipment List
Inspector A � L I1. AN � Date
Vehicle Radio Call Sign y
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.
Bulb syringe.
House oxygen with 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.
p Portable oxygen system with 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 / 21mm
fittings in the following sizes;
K500cc bag with transparent masks for infant and neonate.
,(p) 750cc bag with transparent masks for children.
1000cc bag with transparent masks for adult.
Nasopharyngeal airways in adult sizes 24 fr. through 32 fr,
Oropharyngeal airways in adult and pediatric sizes to include: infant, child, small
adult, adult and large adult.
Patient Assessment Equipment
.0) Blood pressure cuffs to include large adult, regular• adult, child and infant sizes.
-�4) Stethoscope in adult size.
�-j Penlight,
Splinting Equipment
Lower extremity traction splint.
Upper and lower extremity splints.
Long board with equipment to immobilize the patient from head to heels.
2
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.
} Pediatric immobilization device or adult immobilization device that can be
L adapted for pediatric use.
Adult and pediatric cervical spine and head immobilization equipment.
Dressing Materials
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 burr sheets.
1 Adhesive tape, per ambulance service requirements, needs, and Physician Advisor
protocol.
` Sterile irrigation solution.
Obstetrical Supplies
j Sterile OB kit to include: towels, 4x4 dressings, umbilical tape or cord clamps,
scissors, bulb syringe, sterile gloves, and thermal absorbent blanket.
j 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.
j Ambulance Service Medical Treatment Protocols.
Oral glucose.
Stair Chair
Communications Equipment
PeT All communications equipment shall be maintained in good working order. The
communications equipment must be capable of transmitting and receiving clear
voice communications.
I'if S Rcwlif�d 1"quiplimil
3
Two-way communications that will enable the ambulance personnel to communicate
with:
ambulance service's dispatch
Wmedical 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.
�
V Non-sterile surgical masks.
rDisinfectant spray or wipes for personnel and equipment.
()�7 Sharps containers for the appropriate disposal and storage of medical waste and
biohazards.
90 Particulate respirator, N95 type or better.
Safety Equipment
A set of three (3) warning reflectors.
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.
Child safety seat or equivalent
Appropriate protective restraints for patients, crew, accompanying family
members, and other vehicle occupants.
Properly secured patient transport system (i.e. wheeled stretcher).
Triage tags as approved by the Colorado Department of Public Health and
Environment.
( Restraining devices for all items not in a securable cabinet.
{�c 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.
Applif ion or AT ba n�ermit
Service Information
Service Name: 13ASALT- Y t-{uRRL �t�� hRai��Ttory biST�Rtc:C
Address: l-'89 w Dxwi-
Street/P.O.
Communication: gao-Wi-Ob'45
Voice
Vehicle Information
Radio
Radio Call Sign: +" L(O
O�VRPONOALIE co
City State
q--40- 104 -O CL5
Fax
License Plate; g', -t A TK
VIN: 4X4 Yes (X) No ( )
iCGS-JK3yM4rAq'L134
Year: 7-OaN Make: t-, "CV Type: 1
Where will Vehicle be Stationed: s' -t-1 pti r y 4
Waiver Request (Include Reason for Request)
w -L3
Zip
T, cE>rRO,,Lts QbrySr6-W1I
IF -Mail
EIC-HO-vEIC-HO-vRh Co tY L e 'L Q
nt�
Service Director's Name Signu•e Date
(Ambulance Inspector Use Only)
Valid Insurance Card Yes w No ( )
Valid Registration Card Yes p No ( )
Inspection Fee $50.00 Mechanical Condition Certificate Attached)
Required BLS Equipment List Attached;
Required ALS Equipment List Attached
Pass Inspection fail ( ) Reason for Failure
Inspector's Name Signature
It 12.5-112,
Date
I
Vehicle Safety and Operability Certification
Ambulance Services A
Vehicle Radio Call Sign �t
system Acceptable Non Acceptable Comment
Tires ( }
Wheels
Alignment (_ (�-_--_-
Suspension
Brake System e� (^)
Parking Brake
Headlights
Stop/Turn/Brake Lts. `
Visual Warning Lights
Audible Warning ( ( )
Electrical System of ( )
Exhaust System
Fuel Svstem (t ( 1
Glass/Mhrors ( ( )
Body & Sheet Metal Li (^)
General Present Condition Excellent ( Good {) Moderate( Poor( )
Mileage when Inspected 33,
I,`��'�f , professing to be a motor vehicle
technician with training in the systems listed above, have evaluated the condition of all
systems and have found thein to be in a safe and working condition.
Signature Agency/Company
i 3 Lk- C 1 cs" z €� rz iia .g`✓r e}
Phone Address'Date
This evaluation will not guarantee future safety and or operability of this ambulance
due to conditions beyond the technician's control.
V cllwl�., lwlp(v[i(III
b
§
m
/
0
a ,
_
A. -
w o
[ §® §
§
((
p
\
•
r§
�
G @
k
/§
r®
e o
\)
2}
/ 2
t%
0
PFFKIV COUATY
Required Advanced Life Support Equipment List}
Inspector � lc- Date E� j 2sF
Vehicle Radio Call Sign M LD
Minimum Equipment Requirement for Advanced Life Support Ambulances
r All Equipment Listed In BLS Equipment list
Ventilation Equipment
i 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 5.0-8.0 per Physician Advisor protocol.
VLaryngoscope 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
P9 Portable, battery operated cardiac monitor- defibrillator with strip chart recorder
and adult and pediatric EKG electrodes and defibrillation capabilities.
Pulse oximeter with adult and pediatric sensors.
PElectronic blood glucose measuring device.
In#ravenous Equipment
Adult and pediatric intravenous solutions and administration equipment per
Physician Advisor protocol.
YAdult 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 Basalt and Rural 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.
EICH&RN e-OAWU-LlUS C"-, ".k RLr _ l--1O'11r2
Service Director's Name Signature Date
ALS Required Equipment
Required Basic Life Support Equipment List
Inspector E� N�� Date �'� 2 t3
Vehicle Radio Call Sign M 1/ 0
Minimum Equipment Required for Basic Life Support Ambulance
Ventilation Equipment
1 Portable suction unit, and a house (fixed system) or backup suction unit, with
G wide bore tubing, rigid pharyngeal curved suction tip, and soft catheter suction
tips to include pediatric sizes 6 fi•. through 14 fr.
Bulb syringe.
House oxygen with 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 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 / 21mm
fittings in the following sizes;
500ce bag with transparent masks for infant and neonate.
750ce bag with transparent masks for children.
100 Oce bag with transparent masks for adult.
Nasopharyngeal airways in adult sizes 24 fh through 32 fr.
l Oropharyngeal airways in adult and pediatric sizes to include: infant, child, small
L adult, adult and large adult.
Patient Assessment Equipment
Blood pressure cuffs to include large adult, regular adult, child and infant sizes.
Stethoscope in adult size.
r Penlight.
Splinting Equipment
�<) Lower extremity traction splint.
Upper and lower extremity splints.
( Long board with equipment to immobilize the patient fi-om head to heels.
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.
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
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.
Sterile burn sheets.
Adhesive tape, per ambulance service requirements, needs, and Physician Advisor
protocol.
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.
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 heal source for the ambulance patient compartment.
Ambulance Service Medical Treatment Protocols.
Oral glucose.
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.
W.S It"'kIIIII—c l FAIIIII)II]CIII
' 3
Two-way communications that will enable the ambulance personnel to communicate
with:
,1
ambulance service's dispatch
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.
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
W A set of three (3) warning reflectors.
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.
Child safety seat or equivalent
Appropriate protective restraints for patients, crew, accompanying family
members, and other vehicle occupants.
Properly secured patient transport system (i.e. wheeled stretcher).
Triage tags as approved by the Colorado Department of Public Health and
Environment.
(W Restraining devices for all items not in a securable cabinet.
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.
Applif IooNo r ATRas eKermit
Service Information
Service Name: 13A,5rArL_.t 4 I uf�v�L F�F'� IVEO-j-E�`Tt.63�f
Address: 1Ob`l `3WnR1VC CA-r-BONDA),C Cx €31 23
Street/P.O. City State Zip
Communication: Coo-Io4—()6,j5 `-It -104-0 b
Voice Fax
Vehicle Information
Radio Call Sign: M70 License Plate: 62t 1JQ K
VIN: 4X4 Yes (X) No ( )
1" LA174Hlle- AI- LOK
Year: -2.012- Make: p o R h Type: I
Where will Vehicle be Stationed: s,rrptTlor4 4 z.
Waiver Request (Include Reason for Request)
r C.v s'1�@4 LAS 2D 11
E -Mail �3
RtiC AI)'kiZb--- tai_ l:.i�lCLlt.15 �-r�l C Lc -r tt�Lu�. lz c9 i?,
Service Director's Name Signature ]late
(Ambulance Inspector Use Only)
Valid Insurance Card Yes} No ( )
Valid Registl atiorl Card Yes No ( )
Inspection Fee $$50.00 0 Mechanical Condition Certificate Attached ( )
Required BLS Equipment List Attached �
Required ALS Equipment List Attaehed'�-Ip
Pass Inspection Fail (} Reason for Failure
-------------------
Inspector's Name
Signature
Date
11
Vehicle Safety and Operability Certification
Ambulance Service CASA ur � r �-rje's )i-5 rZ�Q K
Vehicle Radio Call Sign c
System Acceptable Non Acceptable Comment
Tires 0 (,)
Wheels
All neat
Suspension (-f
Brake System
Parking Brake
Headlights
Stop/Turn/Brake Lts.
Visual Warning Lights
Audible Warning
Electrical System
Exhaust System
Fuel System ( (�
Glass/Mirrors ( ()
Body & Sheet Metal
General Present Condition Excellent (vf Good () Moderate( Poor( )
Mileage when Inspected
I, A E- 'z l C V , 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.
Signature Agency/Company
k �
) Cr y - ` 1 (al ti OA 00 kA e C,, S t L,
Phone Address Date
This evaluation will not guarantee future safety and or operability of this ambulance
due to conditions beyond the technician's control.
V t..'hick, �Elti ?C'.l.'l Elsil
N1 cz (D Icr 4 2
COLORADO AUTO INSURANCE IDENTIFICATION CARO
COMPANY NAME, ADDRESS 8 NAIG NQ
A116RICAN ALTERNATIVE INSURANCE CORPORATION
555 College Road East, Princeton, NJ 08543-5242
19720
an authorized Colorado insurer has Issued a policy of automobile 1labiltr Insurance proVding coverage for bodily
Injury, property damage insurance in at ]east the minimum amounts prescrbed by Colorado taw, to:
INSURED NAME 8 ADDRESS
BASALT AND RURAL FIRE PROTECTION
DISTRICT
1089 JSV DRIVE
CARB(XNDALE, CO 81623-0000
POLICY NUMBER
EFFECTIVE DATE
EXPIRAT)QY DATE
VFTSTR2061681
01-01-2013
01-01--2014
MWEIMODEL
YEAR
VEHM IDENtIFIGATiDN NUA98ER
FORD AMBULANCE ALS
2012
lFDUE'4HT3CEA13284
INSJRANCEAGENTIBRQI ER
FUR. DATE
PUR. PRICE ORIGINAL TAXABLE VALUE
VFIS
-
11/09/2011
183 Leader Heights Road
12/07/2011 44
R 9999
York, PA 17405
LIC. FEE ROAD FEE
BRIDGE FEE
(717) 741 -QRI I
7.20 0.00 0.00
3.78 0.00
SEE REVERSE UDE UNIFORM R1321a (Ed. 7.03)
rnl nRAnn RI✓C;IgTRATInN/nWNERSHIPTAX RECEIPT
TYPE PLATE TABAfAL
VIN
EXPIRE
PAS-CNY 621HOK 621HOK 1FDUF4HT3CEA13284
PERM.
TITLE
YR MAKE BODY CWTIPAS
TIC FLEET# FUEL
PREV £XP
44E597515
2012 FOR AM 128
4446 D
FUR. DATE
PUR. PRICE ORIGINAL TAXABLE VALUE
BUS. PATE CO #
URICODE
11/09/2011
157583.00 133,945
12/07/2011 44
R 9999
EM. FEE TITLE FEE PRIOR O.T. OWN TAX
LIC. FEE ROAD FEE
BRIDGE FEE
0.00
7.20 0.00 0.00
3.78 0.00
0.00
RTD TAX
COUNTY TRX CITYIDIST TAX
STATE TAX SPECIAL FEF
OTHER FEE
0.00
0.00 0.00
0.00 0.00
0.00
UNIT N
:Gjflfj:::'c ^z_ - MILES
HI GVW HC DATE
UYYNth SVAMk1MA10NU AULJKtbZ,
BASALT AND RURAL FIRE
PROTECTION DISTRICT
1089 J W DR
CARBONDALE CO 81623
M- �Z SIGNATURE
REQUIRED
ON REVERSE
SIDE.
VALIDATION TOTAL
PAID EAGLE 01 12/01/2011 121923LL(2 B03 Y 10.98 PI
MOTOR VEHICLE INSURANCE IS COMPULSORY IN COLORAt)6, NON-COMPLIANCE IS A MISDEMEANOR TRAFFIC OFFENSE
0
Prmm cou L d
Required Basic Life Support Equipment List
Inspector s C--V1-NN Date 1 kslk
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.
Bulb syringe.
'Q House oxygen with 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 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 15rnrn / 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.
Nasopharyngeal airways in adult sizes 24 fr. through 32 fi.
Oropharyngeal airways in adult and pediatric sizes to include: infant, child, small
adult, adult and large adult.
Patient Assessment Equipment
eVX Blood pressure cuffs to include large adult, regular adult, child and infant sizes.
§fJ Stethoscope in adult size.
k�� Penlight.
Splinting Equipment
P<p Lower extremity traction splint.
Upper and lower extremity splints.
Long board with equipment to immobilize the patient from head to heels.
ill'I P('(1 U II('1 JAI LlII'II �3�i
2
VScoop, 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.
( 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
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.
3 Adhesive tape, per ambulance service requirements, needs, and Physician Advisor
protocol.
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.
j Neonate stocking cap or equivalent.
Miscellaneous Equipment
Heavy bandage scissors, shears or equivalent capable of cutting clothing, belts,
boots, cte.
Two working flashlights.
Blankets and appropriate heat source for the ambulance patient compartment.
Ambulance Service Medical Treatment Protocols.
j Oral glucose.
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.
tti.s Rctj€€ircd F(Ittil)It)e€€t
41
Two—way communications that will enable the ambulance personnel to communicate
with,
ambulance service's dispatch
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.
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
A set of three (3) warning reflectors.
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.
6,;,p Child safety seat or equivalent
Appropriate protective restraints for patients, crew, accompanying family
members, and other vehicle occupants.
Properly secured patient transport system (i.e. wheeled stretcher).
Triage tags as approved by the Colorado Department of Public Health and
Environment.
Restraining devices for all items not in a securable cabinet.
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.
!')I ti IZ .cj ii f_<! L( 111,H)C i
PrrxrfvCOUA7Y
Required Advanced Life Support Equipment List
Inspector nkc qh1\Date
Vehicle Radio Call Sign_ 1'']eA 4 �--
Minimum Equipment Requirement for Advanced Life Support Ambulances
t(i)"� 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 6.0-5.0 per Physician Advisor protocol.
Laryngoscope and blades, straight, and/or curved of sizes 0-4.
Adult and pediatric magill forceps.
Y 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.
Pulse oximeter with adult and pediatric sensors.
e—V Electronic blood glucose measuring device.
Intravenous Equipment
Adult and pediatric intravenous solutions and administration equipment per
Physician Advisor protocol.
j7 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 Basalt and Rural Fire Protection, I certify that this ambulance
carries the equipment listed above. This ambulance meets the nrinirnum 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.
Service Director's Name
AI,g Required E'(]ulprrrrnt
Signature
Date
Applif ioMorARWn�e
rmit
Service Information
Service Name: 13vs4ul -4 RuP-vArL rttR'E rr-oTazT, %otf 1$T tc-T
Address: IQI)9 ;5w t)R%vt�
Street/P.O.
Communication: y'10 -'j 0 4- 66+S
Voice
Vehicle Information
Radio Call ,Sign: '" �nIq,�>
City State
�llog`#04._Oi,"LS
Fax
License Plater p
VIN: 4X4 Yes (X) No ( )
iFDWF"3"jT-1`i E-J3C166 12
Year: -z.Qa'o
Make: r-oiR t,-, Type: I
Where will Vehicle be Stationed: �>mTAoyq 'i 3
Waiver Request (Include Reason for Request)
E -Mail
8W-0
Zip
Rtc_HfA0.(S c-op.nlEw--.r�-rt.�l �f �,u.o�t.,�,,.. Iz1s,j 13
SerAce Director's Name Signature Date
(Ambulance Inspector Use Only)
Valid Insurance Card Yes x w No ( )
Valid Registration Card Yeses No ( )
Inspection Fee $50.00IQ Mechanical Condition Certificate AttachedN
Required BLS Equipment List Attached
Required ALS Equipment List Attached'
Pass Inspection Fail( ) Reason for Failure
- - - - - - - - - - - - - - - - - - - - - - -
Inspector's Name Signature
Date
1
Vehicle Safety and Operability Certification
Ambulance Service j�nsA ��~ � �o rzA� Tr R 1 �r e k ,J k,7 -r L
Vehicle Radio Call Signer
System Acceptable Non Acceptable Comment
Tires
Wheels
Alignment
Suspension
Brake System
Parking Brake
Headlights
Sto /Turn1Brake L•ts.'
Visual Warning Lights
Audible Warning
Electrical S stern
Exhaust System
Fuel S stem
Glass/Mirrors
Sheet
General Present Condition Excellent (V)"" Good( Moderate () Poor( }
Mileage when Inspected 50 , q 3 0
I,•° t�,�a ` c� rz , 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.
ME
Signature Agency/Company
Az .
910 • 'To L( -- D(1�11-
Phone
Address
s (( 2�',,> Date
This evaluation will not guarantee future safety and or operability of this arnbulance
due to conditions beyond the technician's control.
VC11)iCIC 1;3 _ , ; ,
Kala',` 43
COLORADO AUTO INSURANCE IDENTIFICATION CARD
COMPANY NAME, ADDRESS & NAIC N0:
AtdERTCAN ALTERNATIVE TNSURANCE CORPORATION
555 College Road East, Princeton, NT 00543-5241
19720
Fr! authorized Colorado insurer has issued a policy of automobile Fabilty insurance proriding coverage for bodiTy,
injury, property damage Insurance In at least the minimum amounts pras'ribed by Colorado Law, to:
r
INSURED NAME & ADDRESS
BASALT AND RURAL FIRE PROTECTION
DISTRICT
1089 al DRIVE
CARBONDALE, CO 81623-0000
POLICY NUh1BER EFFEGTNE DATE E)TIRAT}Qy DATE
VFISTR2061681 01--01-2013 01-01-2014
MAKE/MODEL YEAR VEHICLE IDENTIFICATION NUS9BER
FORD AI-SULANCE ALS 2000 1FIXIF37MEB96612
INSURANCE AGENT/RRO(FR
VHS
183 Leader Heights Road
Yo*, PA 17405
(717) 741-0911
SEE REVFRSE&DE UNIFORM R1321a (Ed. 7-03)
rnl nRAnh RFI;I.TRATInN/0WNFRSHfPTAX RFCFiPT
TYPE 'PLATE ,TABIVALE VIN
EXPIRE
j
LTX--CNY 052BHF . 052BHF-1FD11F37F1.YEB96612
'PERM.
TITLE
YR MAKE BODY CWTIPAS TIC FLEET#
PREV EXP
44E302803
2400 FOR PK 71 4446
PUR. DATE
PUR. PRICE ;ORIGINAL TAXABLE VALUE :BUS. DATE
CO # UR/CODE
04/25/2000
8591.4.00 63,750 01/19/.2005
44 R 9999
EM. FEE
PRIOR O.T. OWN TAX -.LIC. FEE TITLE FEE
OTHER FEE
0.00
0.00 0.00 3.26 0.00 "0.0(
RTO TAX
COUNTY TAX C€TWDIST TAX STATE TAX
SPECIAL FEE FUE,'
0.00
0.00 0.00 0.00
0.00 D
NI GVW
HC DATE
• UYYNC55 rVfWICIMRiL1M3 HV UTSCJA- : r - jS
$ASAI.T -AND RURAL FIRE- Cb' 1 C lam]
,PROTECTION DISTRICT 1. I
' _ SIGNATURE
REQUIRED
11089 J W DR ONREVERSE
•:'CARBONDALE CO 81623 SIDE.-
VALIDATION - - TOTAL
." PAID'EAGLE 01 01/1-9/2:005 '083942LLC -R04 Y 3.26 -PT
MOTOR VEHICLE INSURANCE IS COMPULSORY IN COLORADO, NON•COMP11ANCE IS A MISDEMEANOR TRAFFIC OFFENSE
Required Advanced Life Support Equipment List
Inspector `c RM sem Date Y 1 3
Vehicle Radio Call Sign
Minimum Equipment Requirement for Advanced Life Support Ambulances
V 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 Physician Advisor protocol.
Laryngoscope and blades, straight, and/or curved of sizes 0-4.
60 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 chatt recorder
( and adult and pediatric EKG electrodes and defibrillation capabilities.
IN
Pulse oximeter with adult and pediatric sensors.
YElectronic blood glucose measuring device.
Intravenous Equipment
6AAdult and pediatric intravenous solutions and administration equipment per
T -
Physician Advisor protocol.
`t 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 Basalt and Rural 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,
12 a g 1 1-3
Service Director's Name Signature Date
ALS Regwred E(1Lii1m)cnt
PFFK 1V COUNTY
Required Basic Life Support Equipment List
Inspector 21C. 4ArN S'&r,/ Date �Jt -2- 5 3
Vehicle Radio Call Sign q ?;,
Minimum Equipment Required for Basic Life Support Ambulance
Ventilation Equipment
Portable suction unit, and a house (fixed systen-1) 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 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 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 / 21min
fittings in the following sizes;
500ce bag with transparent masks for infant and neonate.
750cc bag with transparent masks for children.
1000cc bag with transparent masks for adult.
Nasopharyngeal airways in adult sizes 24 fr. through 32 fr.
` Oropharyngeal airways in adult and pediatric sizes to include: infant, child, small
adult, adult and large adult.
Patient Assessment Equipment
Y, Blood pressure cuffs to include large adult, regular adult, child and infant sizes.
Stethoscope in adult size.
Penlight.
Splinting Equipment
Lower extremity traction splint.
W Upper and lower extremity splints.
6(*�,) Long board with equipment to immobilize the patient from head to heels.
BLS Re(julred Ecloilmient
2
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.
Pediatric immobilization device or adult immobilization device that can be
adapted for pediatric use.
Adult and pediatric cervical spine and head immobilization equipment.
Di-essing Materials
`( 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.
Adhesive tape, per ambulance service requirements, needs, and Physician Advisor
protocol.
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.
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 beat source for the ambulance patient compartment.
Ambulance Service Medical Treatment Protocols.
Oral glucose.
le-) 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.
US RCgUil- d F(IIIipnreElt
3
Two-way communications that will enable the ambulance personnel to communicate
with:
Pambulance
service's dispatch
medical control facility or a physician
receiving facilities
Vmutual
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.
( 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
A set of three (3) warning reflectors.
One (1) ten pound (10 lb.) or twyq-)2 ve pound (S lb.) ABC fire extinguishers,
with a minimum of one extinguisher accessible from the atient compartment and
p
vehicle exterior and having been serviced within previous year per NFPA 10
section d.
Child safety seat or equivalent
Appropriate protective restraints for patients, crew, accompanying family
members, and other vehicle occupants.
Properly secured patient transport system (i.e. wheeled stretcher),
{� J Triage tags as approved by the Colorado Department of Public Health and
111 Environment.
Restraining devices for all items not in a securable cabinet.
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 Rent€ircd Equipment
BOCC REGULAR MEETING
DECEMBER 18. 2013
Corrected Applications for Ambulance Permits from corrections made
at the above BOCC Regular Meeting
&t.3
Applif Ion or Abu al nce Permit
Service Information
Service Name: BASi',L'T-'i RuRP�L fiIYLE i w� f'cz Rpt r bVS,M%CT'
Address: load-SkoR\\tE CA-(Z-BONDAt E C-0 .9\623
Street/P.o. City Slate Zip
Communication: q-io-Io4—ob'j5 `l40'lny-0b'L5
Voice Fax
Vehicle Information
Radio Call Sign:MLicense Plate: (,21MOK
VIN: 4X4 Yes (X) No ( )
IFDUF4H13e,VA%3194
Year: 2011 Make: r-oRt> Type: I
Where will Vehicle be Stationed: s 1-qnory 4 s
Waiver Request (Include Reason for Request)
re-&l-y)2,J1I.IS cD,n FIs q \+RrC,ol_3
E -Mail
FICOARL1 L 1 t9'13
Service Director's Name Slgnatnre Date
(Ambulance Inspector Use Only)
Valid Insurance Card Yes No ( )
Valid Registration Card Yes No ( )
Inspection Fee $50.000 Mechanical Condition Certificate Attached ( )
Required BLS Equipment List Attached 1f�cZ,
Required ALS Equipment List Attached'
Pass Inspection Fail O Reason for Failure
�1L
Signature
Date
I
Nc-cDkc— 42
COLORADO AUTO INSURANCE IDENTIFlCATION CARD
COMPANY NAME, ADDRESS& NAG NO
AMERICAN ALTERNATIVE INSURANCE CORPORATION
555 College Road East, Princeton, NJ 08543-5241
19720
an aWhortaed Colorado Insurer has issued a policy of auiomoilfe IiabhAy Insurance pro wing covens, for bodfly
Injury, property damage insuramus in at Teed the minhnum amounts pressibed by Cobrado Law, to:
INSURED NAME & ADDRESS
BASALT AND RURAL FIRE PROTECTION
DISTRICT
1089 JW DRIVE
CARBONDALE, CO 81623-0000
FOU CY NUMBER EFFECTIVE DATE EKPIRATICN DATE
VFISTR2061681 01-01-2013 01-01-2014
MAKFIMODEL YEAR VEHICLE IDENTIFICATION NUMBER
FORD AMBULANCE ALS 2012 1FOUF4HT3CRA13284
U43URAICE ABENT/BROKER
VFIS
183 Leader Helghis Road
York, PA 17,105
(717) 741-0011
SEE REVERSE SIDE UNIFORM R1321a (Ed. 7-03)
rnl nRAnn RrC;IRTRATION/OWNERSHIP TAX RECEIPT
TYPE PLATE TARNAL -
VIN
EXPIRE
PAS-CNY 621HOK 621HOK IFDUF4HT3CEA13284
PERM.
TITLE
YR MAKE BODY CWT/PAS
TIC FLEET# FUEL
PREV EXP
44E597515
2012 FOR AM 128
4446 D
PUR.DATE
PUR. PRICE ORIGINAL TAXABLE VALUE
BUS.DATE CO A
UR/CODE
11/09/2011
157583.00 133,945
12/07/2011 44
R 9999
W. FEE TITLE FEE PRIOR O.T. OWN TAX
UC. FEE ROADFEE
BRIDGEFEE
0.00
7.20 0.00 0.00
3.78 0.00
0.00
RTD TAX
COUNTY TAX CITYIDIST TAX
STATE TAX SPECIAL FEE
OTHER FEE
0.00
0.00 0.00
0.00 0.00
0.00
UNIT Ykayy�ly,.'
MILES
HI GVW HC GATE
BASALTc AND uRURAL FIRE
PROTECTION DISTRICT
L SIGNATURE
1089 J W DR REQUIRED
CARBONDALE CO 81623 ON REVERSE
SIDE.
VALIDATION TOTAL
PAID EAGLE 61 12/01/2011 1?1923LLC B03 Y 10.98 PI
MOTOR VEHICLE INSURANCE IS COMPULSORY W COLORAD6, NONCOMPNANCE IS A MISDEMEANOR TRAFFIC OFFENSE
u
9
Two-way communications that will enable the ambulance personnel to communicate
with:
10 ambulance service's dispatch
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.
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
A set of three (3) warning reflectors.
One (1) tcn 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.
Child safety seat or equivalent
Appropriate protective restraints for patients, crew, accompanying family
members, and other vehicle occupants.
Properly secured patient transport system (i.e. wheeled stretcher).
-11-11
Ct-l) Triage tags as approved by the Colorado Department of Public Health and
Environment.
Restraining devices for all items not in a securable cabinet.
Two "NO SMOKING -OXYGEN IN USE" signs, one in cab, one in patient
compartment.
xp Reflective vests, coat or equivalent for each member of the crew normally
assigned.
"• ��nir<:,Ii,c�uilm:ni
PFFKL1V COUNTY
Application for Ambulance Permit
Service Information /J
Service Name A,,We,N AM
AddressO t)e— Aijwy, 1-A 1 CV 8!%lI
StreeVP.O. 1, City p State Zip
Communication ��"I'�`J� _1 -/
voice Fac E -Mail
Vehicle Information
g eqq - V_r
Radio Cull Sin License Plate
VIN I & D V
?0ij ICJ 1 CD E
1`1:990-7
4X4 Yes (✓r No ( )
Year ZDU
Make
6A46
Tvpe /-fes% 1"6Ca
Where will Vehicle be Stationed r7 V
Waiver Request (Include Reason for Request)
(Ambulance Inspector Use Only)
Valid Insurance Card Yes 0 No ( )
Valid Registration Card Yes,0, No ( )
Inspection Fee $50.00 ( ) Mechanical Condition Certificate Attached`/j
Required BLS Equipment List Attacher!
Required ALS Equipment List Attached qQ
Pass Inspection O�_ Fail_( ) Reason for Failure
PFFKIN COUATY
Required Basic Life Support Equipment List
Inspector Cir od Date l -a �
Vehicle Radio Call Sign W-15
Minimum Equipment Required for Basic Life Support Ambulance
Ventilation Equipment
(I._�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.
ulb syringe.
(l.)/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.
(La 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 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;
(lam 500ce bag with transparent masks for infant and neonate.
(L)/ 750cc bag with transparent masks for children.
�OOOcc bag with transparent masks for adult.
lam' 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 )" Blood pressure cuffs to include large adult, regular adult, child, infant, and
neonatal sizes.
(y'`l Stethoscope in adult and pediatric sizes.
(1 Penlight.
(r Pulse oximeter with adult and pediatric sensors
Splinting Equipment
( Lower extremity traction splint.
( Upper and lower extremity splints.
Long board with 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.
Short board or equivalent, with the ability to immobilize the.patient from head to
pelvis.
`Q Pediatric immobilization device or adult immobilisation device that can be
Adapted for pediatric use.
Adult and pediatric cervical spine and head immobilization equipment.
Dressing Materials
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 bum sheets.
( Alcohol swabs or equivalent.
Adhesive tape, per ambulance service requirements, needs, and Physician Advisor
protocol.
yCC} 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.
(� )X Neonate stocking cap or equivalent.
Miscellaneous Equipment
tA. 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.
Ambulance Service Medical Treatment Protocols.
(� Oral glucose.
(-A Spill proof emesis container.
Universal and/or separate male / female urinals.
9(I Stair Chair
.1
Communications Equipment
( i 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:
N ambulance service's dispatch
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
YN minimum 1 box of latex free gloves.
Protective eyewear.
( Non-sterile surgical masks.
Fluid proof gowns with full-length sleeves or equivalent.
XV
(�Q 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
A set of three (3) warning reflectors.
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.
Child safety seat or equivalent
Appropriate protective restraints for patients, crew, accompanying family
members, and other vehicle occupants.
Properly secured patient transport system (i.e. wheeled stretcher).
Triage tags as approved by the Colorado Department of Public Health and
Environment.
Restraining devices for all items not in a securable cabinet.
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.
ID
PrrxwcOUMY
Vehicle Safety and Operability Certification
Ambulance Service Aspen Ambulance District
Vehicle Radio Call Sign _Medic 95_
System Acceatable Non Accei)table Comment
Tires M ( )
Wheels N4 ( )
Alignment 66 ( )
Suspension (1h ( )
Brake System (VI ( )
Parking Brake (moi ( )
Headlights (A ( )
Ston/Turn/Brake Lts. M ( )
Visual Warning Lights (pn
Audible Warning (V) ( )
Electrical System M ( )
Exhaust System (iii ( )
Fuel System M ( )
Glass/Mirrors M ( )
Body & Sheet Metal (1%1 ( )
General Present Condition, Excellent j Good( Moderate( Poor ( )
Mileage when Inspected
1, Mali professing to be a motor vehicle
technician witfi 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.
&iL
Signal rc V Agency/Company
PO, g)trJ-5r ig 7 (�3 SGfyt« Ce"416-
Phone Address Date
This evaluation will not guarantee future safety and or operability of this ambulance
due to conditions beyond the technician's control. I
d,:F,icic Inspcciiol: T II
MKIN COUNTY
Required Advanced Life Support Equipment List
Inspector 6, All A Date
Vehicle Radio Call Sign
Minimum Equipment Requirement for Advanced Life Support Ambulances
All Equipment Listed In BLS Equipment list
VZMotionEquipment
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.
D4 Laryngoscope and blades, straight, and/or curved of sizes 04.
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.
Electronic blood glucose measuring device.
Intravenous Equipment
�vfl Adult and pediatric intravenous solutions and administration equipment per
Physician Advisor protocol.
Adult and pediatric intravenous arm boards.
Pharmacological Agents
1}� Pharmacological agents and delivery devices per Physician Advisor protocol.
Pediatric "length based" device for sizing drug dosage calculations and sizing
equipment.
As Service Director for49 p 1 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.
Date
�2