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NO 011-2014
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BASALT/RURAL FIRE PROTECTION DISTRICT
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The undersigned, representing the Board of County Commissioners (BOCC) of Pitkin County,
t„ti Colorado, does hereby grant a license to the above-named applicant to provide ambulance
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be granted any waivers listed below, and shall be valid for the dates listed below, unless `'
revoked by the BOCC pursuant to the provisions of Title Six (Health and Safety-Ambulance A
M Licensing) of the Pitkin County Code and any other applicable Pitkin County ordinance or law :
$•,,,,,,:, of the State of Colorado. Licensee shall comply with all applicable laws and regulations,
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'1t r WAIVERS GRANTED: Not Applicable tgo
LICENSE VALID FROM: January 1, 2014 through December 31, 2014
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' .x44, The undersigned, representing the Board of County Commissioners (BOCC) of Pitkin County,
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BY AUTHORITY OF THE PITKIN COUNTY BOARD OF COUNTY COMMISSIONERS:
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Robert A. Ittner, Jr., Chair ' Jeanet`• Jones '
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Pei i,T N The undersigned, representing the Board of County Commissioners (BOCC) of Pitkin County, �;;,,;
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5 WAIVERS GRANTED: Not Applicable
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CO LICENSE VALID FROM January 1, 2014 through December 31, 2014 '
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Robert A. Ittner, Jr., Chair Jean- to Jones ,;
Board of County Commissioners Cler 4 o the Board of ounty Commissioners ,
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NO. 008-2014 04 „
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K ' The undersigned, representing the Board of County Commissioners (BOCC) of Pitkin County, ''
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Int The undersigned, representing the Board of County Commissioners (BOCC) of Pitkin County, •,;°
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Board of County Commissioners Clerk . the Board of ounty Commissioners
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Iw The undersigned, representing the Board of County Commissioners (BOCC) of Pitkin County, t7,-S
`n`s I Colorado, does hereby grant a license to the above-named applicant to provide ambulance 1 i;
service within Pitkin County. This license shall have upon it any restrictions listed below, shall h
a• � be granted any waivers listed below, and shall be valid for the dates listed below, unless y
W.K30 revoked by the BOCC pursuant to the provisions of Title Six (Health and Safety-Ambulance .
qx , Licensing) of the Pitkin County Code and any other applicable Pitkin County ordinance or law
r ,: of the State of Colorado. Licensee shall comply with all applicable laws and regulations, ��y.
including but not limited to Article 3.5 of Title 25, Colorado Revised Statutes. 'kit;i
X' RESTRICTIONS/CONDITIONS: Not Applicable
• : WAIVERS GRANTED: Not Applicable .
<,• :' LICENSE VALID FROM January 1, 2014 through December 31, 2014 ;'
� a;; BY AUTHORITY OF THE PITKIN COUNTY BOARD OF COUNTY COMMISSIONERS:
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i January 1, 2013
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Robert A. !liner, Jr., Chair Jean- to Jones
y} Board of County Commissioners Cler to the Board of ounty Commissioners
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I t ,0,, The undersigned, representing the Board of County Commissioners (BOCC) of Pitkin County, �f�'
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Pa: be granted any waivers listed below, and shall be valid for the dates listed below, unless
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Ig ,,� Licensing) of the Pitkin County Code and any other applicable Pitkin County ordinance or law �"
of the State of Colorado. Licensee shall comply with all applicable laws and regulations,
including but not limited to Article 3.5 of Title 25, Colorado Revised Statutes. 1 '{
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„. BY AUTHORITY OF THE PITKIN COUNTY BOARD OF COUNTY COMMISSIONERS:
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itt January 1, 2013 0.
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The undersigned, representing the Board of County Commissioners (BOCC) of Pitkin County,
"'t ; Colorado, does hereby grant a license to the above-named applicant to provide ambulance
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service within Pitkin County. This license shall have upon it any restrictions listed below, shall a
t � , be granted any waivers listed below, and shall be valid for the dates listed below, unless IS
get 9 Y �i¢ ,
t revoked by the BOCC pursuant to the provisions of Title Six (Health and Safety-Ambulances,
Licensing) of the Pitkin County Code and any other applicable Pitkin County ordinance or law
l3, "?` of the State of Colorado. Licensee shall comply with all applicable laws and regulations,
I t�„ `: including but not limited to Article 3.5 of Title 25, Colorado Revised Statutes. P .
st ,y :
, 1
;° RESTRICTIONS/CONDITIONS: Not Applicable
WAIVERS GRANTED: Not Applicable a,,, t
Si, LICENSE VALID FROM: January 1, 2014 through December 31, 2014 l
� ' BY AUTHORITY OF THE PITKIN COUNTY BOARD OF COUNTY COMMISSIONERS:
IM OS e ° ..
Pit j January 1, 2013 �A
I
F \-2C•/! ic-i l__A ii ; 'I at
Robert A. Ittner, Jr., Chair Jean:- e Jones
Board of County Commissioners Cler t o the Board of County Commissioners t
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I PITKIN COUNTY AMBULANCE LICENSE
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! NO. 003-2014 : e
ASPEN AMBULANCE DISTRICT OA
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, MEDIC 95
it The undersigned, representing the Board of County Commissioners BOCC) of Pitkin Count
(�'�, 9 P 9 Y (BOCC) Y.
Colorado, does hereby grant a license to the above-named applicant to provide ambulance ,
I `' service within Pitkin County. This license shall have upon it any restrictions listed below, shall as i
be granted any waivers listed below, and shall be valid for the dates listed below, unless
t revoked by the BOCC pursuant to the provisions of Title Six (Health and Safety-Ambulance h
;4; Licensing) of the Pitkin County Code and any other applicable Pitkin County ordinance or law ! .'ri '
IS of the State of Colorado. Licensee shall comply with all applicable laws and regulations, '
r ; including but not limited to Article 3.5 of Title 25, Colorado Revised Statutes. „ ;:.
,wt
,ifi' RESTRICTIONS/CONDITIONS: Not Applicable
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WAIVERS GRANTED: Not Applicable I: -,.
1.,>7.2., s. 1',
IA LICENSE VALID FROM: January 1, 2014 through December 31, 2014 t
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ail BY AUTHORITY OF THE PITKIN COUNTY BOARD OF COUNTY COMMISSIONERS:
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January 1, 2013
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Robert A. Ittner, Jr., Chair Jeane e Jones
Board of County Commissioners Clerk o the Board of County Commissioners
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" ', PITKIN COUNTY AMBULANCE LICENSE V,
1 `+.<I NO. 002-2014
1 , r' ASPEN AMBULANCE DISTRICT ' '
I I MEDIC 94 r h
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` *-' The undersigned, representing the Board of County Commissioners (BOCC) of Pitkin County, ,AO
d t.11 Colorado, does hereby grant a license to the above-named applicant to provide ambulance „1,
1 service within Pitkin County. This license shall have upon it any restrictions listed below, shall
,2,5;,;11: be granted any waivers listed below, and shall be valid for the dates listed below, unless ■�'
revoked by the BOCC pursuant to the provisions of Title Six (Health and Safety-Ambulance
Licensing) of the Pitkin County Code and any other applicable Pitkin County ordinance or law
FM';_ of the State of Colorado. Licensee shall comply with all applicable laws and regulations, * ;
including but not limited to Article 3.5 of Title 25, Colorado Revised Statutes. 5 iO
*-h! RESTRICTIONSICONDITIONS: Not Applicable orai
ids' WAIVERS GRANTED: Not Applicable
Zvi
t : LICENSE VALID FROM January 1, 2014 through December 31, 2014 t=`
BY AUTHORITY OF THE PITKIN COUNTY BOARD OF COUNTY COMMISSIONERS:
s04 January 1, 2013 '
rit.k: � '1
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Robert A. Ittner, Jr., Chair Jearftte Jones A-
1114 Board of County Commissioners Clem to the Board of ounty Commissioners
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I PITKIN COUNTY AMBULANCE LICENSE ''
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AP NO. 001-2014 's"
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A,a ' ASPEN AMBULANCE DISTRICT ,.....,9.:,:
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1 vim; MEDIC 93
,�,.;
The undersigned, representing the Board of County Commissioners (BOCC) of Pitkin Count
Colorado, does hereby grant a license to the above-named applicant to provide ambulance vs
;µ; service within Pitkin County. This license shall have upon it any restrictions listed below, shall is `p 1.
En +' y K
*',0 be granted any waivers listed below, and shall be valid for the dates listed below, unless S_ i
revoked by the BOCC pursuant to the provisions of Title Six (Health and Safety-Ambulance ,, `;,
,y I Licensing) of the Pitkin County Code and any other applicable Pitkin County ordinance or law
of the State of Colorado. Licensee shall comply with all applicable laws and regulations, fi I
}! including but not limited to Article 3.5 of Title 25, Colorado Revised Statutes. -r'
to.4;l ,r'
le'`'i'j RESTRICTIONS/CONDITIONS: NotA licable
„I PP
6,2 WAIVERS GRANTED: Not Applicable :rt..x
kie LICENSE VALID FROM January 1, 2014 through December 31, 2014 I,
V l 1 K
BY AUTHORITY OF THE PITKIN COUNTY BOARD OF COUNTY COMMISSIONERS: I
t4' January 1, 2013 /
agfi Robert A. Ittner, Jr., Chair Jea _ to Jones / =
Board of County Commissioners Cler to the Board of county Commissioners r;. •
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AGENDA 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 fpllowing entities:
• Aspen Ambulance District: Medic 9 3, Medic 9 Medic 95, Medic 96
/
• Snowmass/Wildcat fire Protection District: Medic 71, Medic 72, Medic 73
• Basalt/Rural Fire Protection District: Medic gel, Medic 42e, Medic 4/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
P177LtNCOUVTV
Ambulance Service Name t1ep&/J 'AM�I'►ce
'4 O'yfii�'G�i-•
Service Area: ( '� ' 4.47 ps
Full year X Partial year
Emergent X Transfer X Special Event x
Number of Ambulances Licensed: "f
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: D2, GimtS M`'^ t1^'� Z•
Address: OLIO I (4 Ie e,,atc /L4 , ,ipevt GO 8lbt,1
Street/P.O.Box City State Zip
Contact Information: qt-91N- 1 -5-71 ;Litt- 1 578
Voice Fax E-Mail
Colorado Medical License Number: -70 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 'on.
Service Director's Signature: / 2' i / /
Date
Physician Advisor's Signature
Date
PUKJN COUNTY
Application for Ambulance Permit
Service Informatio/n
� //�� /J �h
Service Name AsQ%N AM 114 'ln-JL e -- i S l 71 6-1-•
Address 0goi taStie ('lei /ILA
Street/1'.O. City State Zip
Communication 4:30- 1`J71 19Yel- 1g
Voice Fa% E-Mail
Vehicle Information
M(If) !l
Radio Call Sign License Plate V t�S ' ��
VIN I G )—I V e f " i L of °6c7 4X4 Yes (k)-No ( )
Year 20 1 U Make C—M C Type MI
Where will Vehicle be Stationed /1 Vii
Waiver Request(Include Reason for Request)
11G//14 2`7 gl L r /t i1 GL Sd ✓ K /0/11/3
Service Director's Name Si nature Date
(Ambulance Inspector Use Only)
Valid Insurance Card Yes (0 No ( )
- Valid Registration Card Yes (/) No ( )
Inspection Fee S50.00 ( ) Mechanical Condition Certificate Attached N
Required BLS Equipment List Attached (i)
Required ALSEquipment List Attached 3.
Pass Inspection2<). Fail ( ) Reason for Failure
N0JMp tt,C ti-)lzJv ∎ r. Cr".\0
J ,✓
r
-6ea' i PN,,_:L\u-d- 11' D5'L3
Inspector s\amc — Signature —�-- Date
G
1
•
PITKIN COUNTY
Required Basic Life Support Equipment List
Inspector 5re7 -A-4- Aw✓ Date a5-/Z
Vehicle Radio Call Sign 'M
Minimum Equipment Required for Basic Life Support Ambulance
Ventilation Equipment
V) Portable suction unit,and a house (fixed system) or backupsuction unit, with
wide bore tubing, rigid pharyngeal curved Suction tip, and soft catheter suction
tips to include pediatric sizes 6 fr. through 14 fr.
0) Bulb syringe.
{ I-louse 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 ofa 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,ofa 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 15111111 /21min
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.
({.) Nasophanyngeal airways in pediatric and adult sizes.l2 fr. through 32 In
(�) Oropharyngeal airways in adult and pediatric sizes to include: infant, child, small
( adult, adult and large adult.
Patient Assessment Equipment
06 Blood pressure cuffs to include large adult,7egular adult, child, infant, and
neonatal sizes.
Stethoscope in adult and pediatric sizes..
tr$, Penlight.
r 1 Pulse oximeter with adult and pediatric sensors.
■
■ Splinting Equipment
Lower extremity traction splint.
V) Upper and lower extremity splints.
(S Long board with equipment to immobilize the patient from head to heels.
OCT Scoop, vacuum mattress or equivalent, with appropriate accessories to immobilize
The patient from head to heels. .
Y ..
y Short board or equivalent, with the ability to immobilize the patient from head to
pelvis.
, (7C)' Pediatric immobilization device or adult immobilization device that can be
7
Adapted for,pediatric use.
Adult and pediatric cervical spine and head immobilization equipment.
Dressing Materials
(9 Bandages - various types and sizes per agency needs and Physician Advisor
protocol.
Y') Multiple dressings (including occlusive dressings), various sizes per ambulance
service requirements, needs and Physician Advisor protocol.
(r Sterile burn sheets.
K. Alcohol swabs or equivalent.
(7(1 Adhesive tape, per ambulance service requirements, needs, and Physician Advisor
protocol.
' Sterile irrigation solution.
Obstetrical Supplies
0, Sterile 013 kit to include: towels, 4x4 dressings, umbilical tape or cord clamps.
scissors, bulb syringe, sterile gloves, and thermal absorbent blanket.
Y.) Neonate stocking cap or equivalent.
Miscellaneous Equipment
Heavy bandage scissors, shears or equivalent capable of cutting clothing, belts,
boots, etc.
Y" Two working flashlights.
p4 Blankets and appropriate heat source for the ambulance patient compartment.
Ambulance Service Medical Treatment Protocols.
`(n Oral glucose:
/ Spill proof emesis container.
24 Universal and/or separate male! female urinals.
Stair Chair
.
E
1
I 3
Communications Equipment
M. 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 serv'ice's dispatch
01: medical control facility or a physician
(9' receiving facilities
(6 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.
(.74) Protective eycwear.
(2,6 Non-sterile surgical masks.
' ) Fluid proof gowns with full-length sleeves or equivalent:
9Q' Disinfectant spray or wipes for personnel and equipment.
cycsi Sharps containers for the appropriate disposal and storage of medical waste and
biohazards.
Particulate respirator,N95 type or better.
Safety Equipment
a
(0' A set ofthree (3) warning reflectors.
One (I)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
vehicleexterior and having been serviced within previous year per NFPA 10
section 4.
94 Child safety scat or equivalent
Ogtp Appropriate protective restraints for patients, crew, accompanying family
members, and other vehicle occupants.
Properly secured patient transport system (i.e.;wheeled stretcher).
IA 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.
PITKIN COUNTY
Required Advanced Life Support Equipment Lis t
Inspector S, AnT14/ Date i 1/25113
Vehicle Radio Call Sign /14-' 13
Minimum Equipment Requirement for Advanced Life Support Ambulances
(0 All Equipment Listed In BLS Equipment list
Ventilation Equipment
(4 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.
( y/ Adult and pediatric magill forceps.
(4 End tidal CO2 detector or alternative device,approved by the FDA, for
determining correct tube placement.
Patient Assessment Equipment
01 Portable, battery operated cardiac monitor-defibrillator with strip chart recorder
and adult and pediatric EKG electrodes and defibrillation capabilities.
0.4 Electronic blood glucose measuring device.
Intravenous Equipment
(4 Adult and pediatric intravenous solutions and administration equipment per
Physician Advisor protocol.
04 Adult and pediatric intravenous arm boards.
Pharmacological Agents
(4 Pharmacological agents and delivery devices per Physician Advisor protocol.
(J Pediatric"length based"device for sizing drug dosage calculations and sizing
equipment. n
As Service Director for AA- 1J , 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.
daMes AcW144/s d JJ/1//3
Service Director's Name ignature Date
ptrKMTco
Vehicle Safety and Operability Certification
Ambulance Service Aspen Ambulance District
Vehicle Radio Call Sign _Medic 93
System Acceptable Non Acceptable Comment
Tires (.4 ( )
Wheels (4 ( )
Alignment (YS ( )
Suspension (v1 ( )
Brake System ( )
Parking Brake (✓S ( )
Headlights ('4' ( )
Stop/Turn/Brake Lts. (✓( ( )
Visual
Warning Lights (V( ( )
• ° Audible Warning ('-1 ( )
- Electrical System (Yr ( )
Exhaust System (vc ( )
Fuel System (v (
Glass/Mirrors (V1 ( )
• Body& Sheet Metal (A ( 1
General Present Condition, Excellent (9' Good ( ) Moderate( ) Poor( )
Mileage when Inspected t}l122(.47
1, 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 them to be in a safe and working condition.
�* , PFFKIN COUNTS
Signature Agency/Company
970-920-5393 76 Service Center Dr 11-19-2013
'v�. Phone Address Date
I
VC-hide i a.E .pv!..Ct
PITIKIN COUNTY
Application for Ambulance Permit
Service Information t
Service Name Apeti AM 61'1 4 ic--.n/1 e L2;5 1-71 i 6 f- .
Address [)q i Ca 9HHe bi re-( 6,11 flye--1 6 a gib/I
Street/P.O. Cifr Slate Zip
Communication ijq-i57I i;4fy-15'8
voice ras h;daft
Vehicle Information JJ�7 j
Radio Call Sign McV1 License Plate D D3-c-1 vI
VI? 1 T r- Li 14-1-0C " 9Yci5{v 4X4 Yesc) No ( )
Year -;01 -7-' Make} }-Ut 0! Type /J �1
Where will Vehicle be Stationed `"t V H
Waiver Request (Include Reason for Request)
'Afrie fi,r6Ur-161.Si4 1✓ � 8729/i 3
Service Director's Name at,u.nure L. Date
(Ambulance Inspector Use Only)
Valid Insurance Card Yes I No ( )
Valid Registration Card Yes( No ( )
Inspection Fee S50.00 ( ) Mechanical Condition Certificate Attachedt(-4
Required HIS Equipment List Attached
Required ALS Equipment List Attached (
Pass Inspection F, Fail ( ) Reason for Failure
DN.v
y�� Jm v\c i" t)icr1 t,` :cam'.- - `,,,f1
J v i , I
3cot1- IM4\�.,— .� -- 11-25 -1.3
- — — — -- —
Inspector's Name Sign:IInre etc
1
PITICIN COUNTY
Required Basic Life Support Equipment List
Inspector ��' CorrP\-4-a-4vtr Date 1V- S-(3
Vehicle Radio Call Sign I\It°< -(
Minimum Equipment Required for Bask 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.
[-louse 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.[.M.
• Transparent: non-rcbreather oxygen masks and nasal cannulas in adult and
pediatric sizes.
Bag-valve mask resuscitators with oxygen reservoirs and standard 15mm r 21 mm
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.
(}l 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.
9 Stethoscope in adult and pediatric sizes.
14,) Penlight.
04 Pulse oximeter with adult and pediatric sensors.
7
•
Splinting Equipment
9".) Lower extremity traction splint.
QQ Upper and lower-extremity sp lints:
V) Long board with equipment to_immobilize the patient from head to heels:
90 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.
Y ' 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
N Bandages - various types and sizes per agency needs and Physician Advisor
protocol.
(r• Multiple dressings (including occlusive dressings), various sizes per ambulance
service requirements, needs and Physician Advisor protocol.
(r Sterile burn sheets'.
y' Alcohol swabs or equivalent.
ep Adhesive tape, per ambulance service requirements, needs, and Physician Advisor
protocol.
(g Sterile irrigation solution.
Obstetrical Supplies
QG Sterile OB kit to include`. towels, 4x4 dressings; umbilical tape or cord clamps;
scissors, bulb syringe, sterile gloves, and thermal absorbent blanket.
(Of Neonate stocking cap or equiva lent.
Miscellaneous Equipment
(A Heavy bandage scissors, shears or equivalent capable of cutting clothing, belts,
boots, etc.
54 Two working flashlights.
/( Blankets and appropriate heat source for the ambulance patient compartment.
(7 Ambulance Service Medical Treatment Protocols.
Val Oral glucose.
Spill proof cmesis container.
94, Universal and/or separate male / female urinals.
Stair Chair
, �t E'e. %-k1
Communications QC), 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 •
('1`) medical control facility or a physician
receiving facilities
gC) mutual aid agencies.
Body Substance Isolation Properly Sized To Fit All Personnel To Include;
(?5, Non-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.
('sr) Fluid proof gowns;with full-length sleeves or equivalent. ,
C6 Disinfectant spray or wipes for personnel and equipment.
CO Sharps Containers fog r the appropriate disposal"and storage of medical waste and
biohazards.
OC) Particulate respirator,N95.type or better..
Safety Equipment
1 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.
()(j, Child safety seat or equivalent
0). Appropriate protective restraints for patients, crew, accompanying family
members, and Other vehicle occupants.
Properly secured patient transport system (i.e. wheeled stretcher).
pq Triage tags as approved by the Colorado Department of Public Health and.
Environment.
�4. Restraining devices for all items not in a securable.cabinet.
ctei Two "NO SMOKING-OXYGEN IN USE" signs, one in cab, one in patient
compartment.
O_ Reflective vests, coat or equivalent for each member oldie crew normally
assigned.
•
I'ITKINCOUNTY
Vehicle Safety and Operability Certification
Ambulance Service Aspen Ambulance District
Vehicle Radio Call Sign Medic 94
System Acceptable Non Acceptable Comment
Tires (t.Y ( )
Wheels (tY ( 1
Alignment (r.Y ( )
Suspension (t-Y ( 1
Brake System (0/ ( )
Parking Brake (/,Y ( )
Headlights (aY ( )
Stop/Turn/Brake Lts. ( at- ( )
Visual Warning Lights( 47 ( )
Audible Warning ('Y ( )
Electrical System (Jr ( )
Exhaust System (c ( )
Fuel System (47 ( )
Glass/Mirrors (4Y ( )
Body&Sheet Metal (tX ( )
General Present Condition, Excellent(-y-- Good ( ) Moderate( ) Poor( )
Mileage when Inspected ' I t 41
I, c m G PS ∎ l[(4 rv• ,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.
//1 ( �[ f
(4.214 �2./.C�I n.� �r�NA/ ' vJ//`/re/ �.(AJ`e
s• ure Agency/Company 6
QM 9.219 S Ro S 74' Sertn c e Ceruierieel I/ri /(//.37/3
Phone Address 1 Date
r
This evaluation will not guarantee future safety and or operability of this ambulance
due to conditions beyond the technician's control.
Vehicle In:apcctUn-
PITKINCOUNTY
Required Advanced Life Support Equipment List
Inspector S . f}nJul4 _ Date 1112 /0.
Vehicle Vehicle Radio Call Sign ,14 ` '.,
Minimum Equipment Requirement for Advanced Life Support Ambulances
eic All Equipment Listed In BLS Equipment list
Ventilation Equipment
(111 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.
(J' Adult and pediatric magill forceps.
(9/ End tidal CO2 detector or alternative device,approved by the FDA, for
determining correct tube placement.
Patient Assessment Equipment
(4 Portable, battery operated cardiac monitor-defibrillator with strip chart recorder
and adult and pediatric EKG electrodes and defibrillation capabilities.
(t( Electronic blood glucose measuring device.
Intravenous Equipment
(ti Adult and pediatric intravenous solutions and administration equipment per
Physician Advisor protocol.
(14' 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 4 f7 y}
0. , 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.
,(gMes gC1441,1djan/ Vv`�/ /2/1�13.
Service Director's Name 'gnature Date
PITKIIN COUNTY
Application for Ambulance Permit
Service Information n
Service Name Ae,OeN AM&I c-' 'c e I/;s)"- i r f
i
Address°4ui Ct,st-)c &i, t< /Z4 4,/e-,' , 6° glol l
SirceVKO. City State Zip
Communication 9111-1-17-1 I .S'7l-1 'igl)
Voice Fm F.-Mail
Vehicle Information
r - Pi ✓-
Radio Call Sign 'NA��C�J 1 License Plate Uy
VIN I L7:11 ��b I g e /'1 Au07 4X4 Yes .-)-No ( )
Year L�
Z vu Make 6446 Type 4/4/4/1K61 .M 1//el.
Where will Vehicle be Stationed Au hi-'
Waiver Request(Include Reason for Request)
.3t e5 d«tiu-Iccst,..: (7-1774,---- /z-ii //3
•
Service Director's Name Sign ire Date
(Ambulance Inspector Use Only)
Valid Insurance Card Yes 4 No ( )
Valid Registration Card Yes,(/). No ( )
Inspection Fee 550.00 ( ) Mechanical Condition Certificate Attached
Required BLS Equipment List Attached.)
Required ALS Equipment List Attached VA
Pass Inspection 4 Fail ( ) Reason for Failure
3
u( ( A:,.V 1 t,f 1\.R 5- i 3
truprclor s Name Signsturc Woe
■
1.
• PJTKIN COUNTY
Required Basic Life Support Equipment List
Inspector Sc c ±l f\r*Au tt Date I ( - 1
Vehicle Radio Call Sign f\Aci a�
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 ft. through 14 fr.
(v( B lb syringe.
l4 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.
(LK Portable oxygen system With a minimum storage capacity of 15 c.f.: (D cylinder)
and a minimum delivery capability for I-patient at flows of a least 1-15 L.P.M.
(LK Transparent, non-rebreather oxygen masks and nasal cannulas in adult and
pediatric sizes.
Bag-valve mask resuscitators with oxygen reservoirs and standard 15mm / 21nnn
fittings in the following sizes;
• (la r,. 500cc.bag with transparent masks for infant and neonate.
(LK 750cc bag with transparent masks for children.
(L)/1000ce bag with transparent masks for adult.
(LK- Nasopharyngeal airways in pediatric and adult sizes 12 fr. through 32 fr.
•
(L ' Oropharyngeal airways in adult and pediatric sizes to include: infant, child, small
adult, adult and large adult.
Patient Assessment Equipment
(L')" Blood pressure cuffs to include large adult, regular adult, child, infant, and
neonatal sizes.
@t-).- Stethoscope in adult and pediatric sizes.
(1.K Penlight.
•
(G)- Pulse oximeter with adult and pediatric sensors:
. i
.
Splinting Equipment
p9, Lower extremity traction splint.
{4 Upper and lower extremity splints.
c4;' Long board with equipment to immobilize the patient from head to heels.
(21„ Scoop, vacuum mattress or equivalent, with appropriate accessories to immobilize
The patient from head to beds.
c/), 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.
.145 , 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.
(f), Sterile burn sheets.
(./),_ Alcohol swabs or equivalent.
Adhesive tape, per ambulance service requirements, needs, and Physician Advisor
protocol.
5/,) 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-1 Neonate stocking cap or equivalent.
Miscellaneous Equipment
21. Heavy bandage scissors, shears or equivalent capable of cutting clothing, belts,
boots.etc.
Two working flashlights.
�isN/ Blanketsand appropriate heat source for the ambulance patient compartment.
. Ambulance Service Medical Treatment Protocols.
(X Oral glucose.
(E' Spill proof cmesis container.
(rj., Universal and/or separate male / female urinals.
%) Stair Chair
iti
3
Communications Equipment
(.:4 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:
(?j ambulance service's dispatch
6 medical control facility or a physician
receiving facilities
(i) mutual aid agencies.
Body Substance Isolation Properly Sized To Fit All Personnel To Include;
Y6 Non-sterile disposable gloves in small, medium, and large sizes, to include a
minimum 1 box of latex free gloves.
Protective cyewear.
( Non-sterile surgical masks.,
Xv Fluid proof gowns with full-length sleeves or equivalent.
" Disinfectant spray or wipes for personnel and equipment.
SSharps containers for the appropriate disposal and storage of medical waste and
/ biohazards.
56 Particulate respirator,N95 type or better.
Safety Equipment
Yh4� A set of three (3) warning reflectors,
(4 One(I) ten pound (10 lb.)or two (2) live pound(5 lb.) ABC fire extinguishers,
/ with a minimum of one extinguishes accessible from the patient compartment and
vehicle exterior and having been serviced within previous year per NFPA 10
section 4.
(4' Child safety seat or equivalent
OO Appropriate protective restraints for patients, crew, accompanying family
members, and other vehicle occupants.
0 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.
Q(). Two NO SMOKING-OXYGEN IN USE" sighs, one in cab, one in patient
compartment.
Reflective vests, coat or equivalent for each member of the crew normally
assigned.
PITIKIPcount
Vehicle Safety and Operability Certification
Ambulance Service Aspen Ambulance District
Vehicle Radio Call Sign Medic 95_
System Acceptable Non Acceptable Comment
Tires 04 ( )
Wheels (vi ( )
Alignment (✓) ( )
Suspension (dl (1
Brake System (vj ( )
Parking Brake (t/1 ( )
Headlights (14 ( )
Stop/1'um/Brake Lts. (1VS ( )
Visual Warning Lights(e1( ( )
Audible Warning (V) ( )
Electrical System (VS ( )
Exhaust System (41 (
Fuel System (V( ( )
Glass/Mirrors ("3 ( 1
Body&Sheet Metal M ( )
General Present Condition, Excellent ti7 Good( ) Moderate( ) Poor( )
Mileage when Inspected 2-1.11S
1,
.1404 (cc c*« `( , 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.
ptfv Cu
Signature Agency/Company
r110 s'0 -5 i/3 1 C SCrVirc Cetiirti loll, it 611010
Phone Address Date
This evaluation will not guarantee future safety and or operability of this ambulance
due to conditions beyond the technician's control.
Vcliicli Inspection
P11KIN COUNTY
Required Advanced Life Support Equipment List
Inspector 5, Mali Date lI 125/13•
Vehicle Radio Call Sign M-qs
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 /`t�J
4 0 , 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.
�MeS
A4 613//4/ — /Z///,
Service Director's Name Si ature Date
PITICIN COUNTY
Application for Ambulance Permit
Service Information �j 6-74 �}
Service Name g C- i 4" 4 lc / h'S *1 I Of, /�
Address OLi0 tc he Ci -U 174 i A flew( C° Z/b( l
Street/r.O. City / State 'Lip
Communication 544- I91( `iyN-1SRo
Voice
Fax E-Mail
Vehicle Information
Radio Call Sign i\ACI License Plate 14.3— f i tip
VIN 1 (9 vv l 3 1 t2 . Z E!_ (5355c/- 4X4 Yes No ( )
Year 7 U`u R Make f71-cA Type 4 t
Where will Vehicle be Stationed 4 b L4
Waiver Request(Include Reason for Request)
��/iq 2s /Ut�G dtsv ✓ l/�C-✓� i Z/l[ (;:
Service Director's Name Sigr lure Date
(Ambulance Inspector Use Onlvl
Valid Insurance Card YesjS) No ( )
Valid Registration Card Yes (X No ( )
Inspection Fee S50.00 ( ) Mechanical Condition Certificate Attached vi
Required BLS Equipment List Attached iX)
Required ALS Equipment List.Attached ( )
Pass Inspection (>4".Fail ( ) Reason for Failure
$oSrAoktns `J` U(V \V\ cc., 0
5L. It r*V u 11—a6- i 3
Inspector's Name — --Sienainre— -- 71atr
1
COUNTY
g
PITKILV C' am/
Required Basic Life Support Equipment List
Inspector 5coi4 A~' Lc"- Date "U-a3-I�
Vehicle Radio Call Sign N\
Minimum Equipment Required.for Basic Life Support Ambulance.
Ventilation Equipment
v 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.
(7Y 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.
(rc Portable oxygen system with minimum storage capacity of 15 c.f.. (D cylinder)
and a minimum delivery capability for I-patient at flows ofa least 1-I5 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;
500cc bag with transparent masks for infant and neonate.
O) 750cc bag with transparent masks for children.
(yf 1000cc bag with transparent masks for adult.
(0' 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
y 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.
2
Splinting Egnipmcnt
94 Lower extremity traction splint.
(} Upper and lower extremity splints.
vi Long board with equipment to immobilize the patient.from head to heels..
Ica Scoop, vacuum mattress or equivalent, with appropriate accessories to immobilize
The patient from head to heels.
(7). Short board or equivalent, with the ability to immobilize the patient from head to
pelvis.
(xj_ 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
pQ 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.
Q(4 Sterile burn sheets.
ep Alcohol swabs or equivalent.
( - Adhesive tape, per ambulance service requirements, needs, and Physician Advisor
protocol.
(4 Sterile irrigation solution.
Obstetrical Supplies
(X) 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
V) Heavy bandage scissors, shears or equivalent capable of cutting clothing, belts,
boots, etc.
Two working flashlights.
rQCf Blankets and appropriate heat source for the ambulance patient compartment.
r ' Ambulance Service Medical Treatment Protocols.
!� Oral glucose.
K.. Spill proof emesis container.
(y Universal and/or separate.male / female urinals.
Stair Chair
{
3
Communications Equipment
It) All communications equipment shall be maintained in good \corking 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:
()9 ambulance service's dispatch
(1) medical control facility or a physician
( receiving facilities.
Y l 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.
Ty) Protective eyewear.
( ' Non-sterile surgical masks.
(),() Fluid proof gowns with full-length sleeves or equivalent.
t Disinfectant spray or wipes for personnel and equipment.
'¢C5` Sharps containers for the appropriate disposal and storage of medical waste and
biohazards.
ix).- Particulate respirator, N95 type or better.
Safety Equipment
A set of three(3) warning reflectors.
111, One (I) 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
p; Appropriate protective restraints for patients, crew, accompanying family
members. and other vehicle occupants:
QC 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.
(Kc;, 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.
7.
•
rITIhIN COUNTY
Vehicle Safety and Operability Certification
Ambulance Service Aspen Ambulance District '
Vehicle Radio Call Sign. Medic 96_
System Acceptable Non Acceptable Comment
Tires (n) ( )
Wheels (os) ( )
Alienment (x) ( )
Suspension (x) ( )
Brake System (c0 ( )
Parking Brake (oi (' )
Headlights (Xl ( )
Stop/Turn/l3rake Us. (Y3 ( )
Visual Warming Liuhts (x) (
Audible Warning (K) ( )
Electrical System (I) (
Exhaust System (>O ( )
Fuel System (X) ( )
Glass/Mirrors (x) ( )
Body & Sheet Metal ('x)
General Present Condition. Excellent (7y Good ( ) Moderate ( ) Poor( )
Mileage when Inspected -129��
I, fit(- professing to be a motor vehicle
technician wit 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
9.}o-92Q- 53'13 7 cCo{ (mkt p4 1/-2i 1.3
Phone Address- Date
•
77a . .
LwII 121gat
•
4‘A1/4 3+0 511 . .
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
PITKIN COUNTY
Required Advanced Life Support Equipment List
Inspector 4j . 41(111"-"" Date I I/2,/13-
Vehicle Radio Call Sign 44-96
Minimum Equipment Requirement for.Advanced Life Support Ambulances
(9" All Equipment Listed In BLS Equipment list
Ventilation Equipment
(✓f 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.
elf Laryngoscope and blades, straight, and/or curved of sizes 0-4.
(t.)f Adult and pediatric magill forceps.
( a' End tidal CO2 detector or alternative device,approved by the FDA, for
determining correct tube placement.
Patient Assessment Equipment
()I Portable, battery operated cardiac monitor-defibrillator with strip chart recorder
and adult and pediatric EKG electrodes and defibrillation capabilities.
(c/ Electronic blood glucose measuring device.
Intravenous Equipment
( 1/ Adult and pediatric intravenous solutions and administration equipment per
Physician Advisor protocol.
(se Adult and pediatric intravenous arm boards.
Pharmacological Agents
(4 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 40o.
, 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.
.‘M&5 GUL1e a (Li t/i
—Service Director's Name Signature Date
P177CIN COUNTY
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.Hot City State Zip
Contact Information: 970-922-6000 same ebalkomd n,gmail.com
Voice Fax E-Mail
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: /NE/./71 `- /2. /3
Dale
Physician Advisor's Signature
Date
ppL*Pt p:
Application n or Am bu ance ermit
Service Information
Service Name: Snowmass-Wildcat Fire Protection District
Address: PO Box 6436 Snowmass Village CO 81615
SIrCCUP.O. City State Zip '..
Communication: 970-923-2212 970-923-2224 sarthurAswfpd:com
Voice Fax E-Mail
Vehicle Information
Radio Call Sign: M71 License Plate: 447 HVJ
YIN: I FDWF37PX5EDI3429 .4X4 Yes ( X ) No ( )
Year: 2005 Make: Ford Type:_I
Where will Vehicle be Stationed: 5275 Owl Creek Road. Snowmass Village, CO
Waiver Request(Include Reason for Request)
John Mele A /2 -5/3
Sen ice Director's Name Signature Date
/,� (Ambulance Inspector Use Only)
Valid Insurance Card Yes r'�i No ( )
Valid Registration Card Yes f4. No ( )
Inspection Fee$50.00 VA_ Mechanical Condition Certificate Attached 44.
Required BLS Equipment List Attached (D9.
Required ALS Equipment List Attached (c4
P nspecti I a ( ) Fail ( ) Reason for Failure
/
Inspector's Name Sign• e Date
COURT"'
Vehicle Safety and Operability Certification
Ambulance Service. Snowmass-Wildcat Fire Protection District
Vehicle Radio Call Sign NCI CI.
System Acceptable Non Acceptable Comment
Tires ►d f
Wheels 1)C) ( )
Alignment fl ( )
Suspension (/) O
Brake System (/J ( ) /- *)2 /C )�2
Parking Brake ( )
Headlights ( ( )
Stop/Tum/Brake Lts. (X) ( )
Visual Warning Lights (�) ( )
Audible Warning ( )
Electrical System ()
Exhaust System ( )
Fuel System ( )
Glass/Mirrors c
Body & Sheet Metal (V (
c_ JYlq// /e /c L 64c4. of t°,1j;/c,
General Present Condition 7 g Excellent( ) Good j, Moderate ( ) Poor( )
Mileage when Inspected 7 / 1513 I, go>4 /W c />(// professing to be a motor vehicle
technician with training in the systems listed above; have evaluated the condition of all
syste and h 4e ound them to be in a safe and working condition./
Signature AgencyiCompany
. ?7o -9z?-11/a .? 711471 di Pi. cmj. Kd /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.
chick In pc iitw
1
PIT7IIN COUNTY
Required Basic Life Support Equipment List
Inspector Ot4.1- • Date /Z/01
Vehicle Radio Call Skin /17/
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
rips to include pediatric sizes 6 fr. through 14 fr.
04 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.
(y,( 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;
500cc bag with transparent masks for infant and neonate.
yCj 750cc bag with transparent masks for children.
y(( 1000cc bag with transparent masks for adult.
Nasopharyngeal airways in adult sizes 24 fr. through 32 fr.
(4 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.
(pet Stethoscope in adult size.
44 Penlight.
Splinting Equipment
Lower extremity traction splint.
(p, Upper and lower extremity splints.
(sQ Long board with equipment to immobilize the patient from head to heels.
IiI ti I:ryuircil I yuihni ul
2
Scoop,vacuum mattress or equivalent,with appropriate accessories to immobilize
The patient from head to heels.
(pd_ Short board or equivalent, with the ability to immobilize the patient from head to
pelvis.
(pal. Pediatric immobilization device or adult immobilization device that can be
adapted for pediatric use.
GO( Adult and pediatric cervical spine and head immobilization equipment.
Dressing Materials
p4 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.
j Sterile bum sheets.
K Adhesive tape,per ambulance service requirements,needs, and Physician Advisor
protocol.
44 Sterile irrigation solution.
Obstetrical Supplies
(p( Sterile OB kit to include: towels,4x4 dressings,umbilical tape or cord clamps,
scissors,bulb syringe,sterile gloves, and thermal absorbent blanket.
44, Neonate stocking cap or equivalent.
Miscellaneous Equipment
tyet Heavy bandage scissors,shears or equivalent capable of cutting clothing,belts,
boots,etc.
94. Two working flashlights.
(pi:j. Blankets and appropriate heat source for the ambulance patient compartment.
(pi_ Ambulance Service Medical Treatment Protocols.
4)4 Oral glucose.
(i( Stair Chair
Communications Equipment
(DQ All communications equipment shall be maintained in good working order. The
communications equipment must be capable of transmitting and receiving clear
voice communications.
it 1/4. kcyun.vl I`.yuilnurnl
3
Two-way communications that will enable the ambulance personnel to communicate
with:
ambulance service's dispatch
(QQ medical control facility or a physician
(X_ receiving facilities
(4 mutual aid agencies.
Body Substance Isolation Properly Sized To Fit AU Personnel To Include;
Pt Non-sterile disposable gloves in small,medium,and large sizes, to include a
minimum 1 box of latex free gloves.
j Protective eyewear.
44 Non-sterile surgical masks.
Disinfectant spray or wipes for personnel and equipment.
(pj_ Sharps containers for the appropriate disposal and storage of medical waste and
biohazards.
(4 Particulate respirator, N95 type or better.
Safety Equipment
(4 A set of three(3)warning reflectors.
(p{( • 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.
(4 Child safety seat or equivalent
k& Appropriate protective restraints for patients, crew, accompanying family
members,and other vehicle occupants.
(4 Properly secured patient transport system(i.e. wheeled stretcher).
(pct Triage tags as approved by the Colorado Department of Public Health and
Environment.
Restraining devices for all items not in a securable cabinet.
(4 Two"NO SMOKING-OXYGEN IN USE"signs,one in cab,one in patient
compartment.
Q4 Reflective vests,coat or equivalent for each member of the crew normally
assigned.
ItI ti Rcyuiral I•yuihnirni
PHKIN COUNTY
Required Advanced Life Support Equipment List
Inspector C/101/9 Date/L.VJ
Vehicle Radio Call Sigh /r7/
Minimum Equipment Requirement for Advanced Life Support Ambulances
All Equipment Listed In BLS Equipment list
Ventilation Equipment
(pcj 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=3.0 per Physician Advisor protocol.
Laryngoscope and bladds. 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
(pd Portable, battery operated cardiac monitor-defibrillator with strip chart recorder
and adult and pediatric EKG electrodes and defibrillation capabilities.
(4 Pulse oximeter with adult and pediatric sensors.
(pd Electronic blood glucose measuring device.
Intravenous Equipment
(per Adult and pediatric intravenous solutions and administration equipment per.
Physician Advisor protocol.
(k).. Adult and pediatric intravenous arm boards.
Pharmacological Agents
(p)._ 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-Wildeat 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 f, /2-5=/3
Service Director's Name tature Date
Application for & u a ermit
Service Information
Service Name: Snowmass-Wildcat Fite Protection District
Address: PO Box 6436 Snowmass Villase CO 81615
Street/P.O. City State Zip
Communication: 970-923-2212 970-923-2224 sarthura,swfpd.com
.. - Voice Fps Entail
Vehicle Information
Radio Call Sign: M72. License Plate: 887 GPW
VIN: 1 FDUF4HT5CE850579 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)
i f
John Mele
Sen'iee Director's Name Signature Date
(Ambulance Inspector Use Only)
Valid Insurance Card Yes m4 No ( )
Valid Registration Card Yes (4 No ( )
Inspection Fee 550.00 04 Mechanical Condition Certificate Attached 06
,Required BLS Equipment List Attached ( )
Required ALS Equipment List Attached ( )
'ass Inspection ) Fail ( ) Reason for Failure
CScto:'s (yU+SM4 � 3 !Z/ae
Inspector's Name tf gnalnre ' Du e
PITKIN COUNTY
Required Advanced Life Support Equipment List
Inspector Cerifrtiki Date /2/,S'/3
Vehicle Radio Call Sidi A 71 l/
Minimum Equipment Requirement for Advanced Life Support Ambulances
(< All Equipment Listed In BLS Equipment list
Ventilation Equipment
Q4- Adult and pediatric endotracheal intubation equipment to include stylcts and an
endotracheal tube stabilization device and endotracheal tubes uncufTcd sire 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.
04 Adult and pediatric magill forceps.
(X)... End tidal CO, detector or alternative device, approved by the FDA. for
determining correct tube placement.
Patient Assessment Equipment
AO} Portable. battery operated cardiac monitor-defibrillator with strip chart recorder
and adult and pediatric EKG electrodes and defibrillation capabilities.
09 Pulse blimeter with adult and pediatric sensors.
4 Electronic blood glucose measuring device.
Intravenous Equipment
Adult and pediatric intravenous solutions and administration equipment per
Physician Advisor protocol.
(P4 Adult and pediatric intravenous arm boards.
Pharmacological Agents
Js Pharmacological agents and delivery devices per Physician Advisor protocol.
(xi 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.
JohnMele % 4-573
Service Director's Name Signature Date
ALS Required
PITICIN COUNTY
Vehicle Safety and Operability Certification
Ambulance Service Snowmass-Wildcat Fire Protection District
Vehicle Radio Call Sign atiWQ
System Acceptable Non Acceptable Comment
Tires (t) ( ) r HA L 1Z 134 L
Wheels OC) ( )
Alignment (Y) ( ) y
r,;;,>.. '-,tc.A.frc /jr- Nei it
Suspension (y) ( ) fad /X.- d rah6,,yl-p,:/c.
Brake System T/) ( ) ,i 7o�E 9 'a/
Parking Brake NO ( )
Headlights b<) ( )
Stop/Tutu/Brake Lts. 00 ()
Visual Warning Lights (y) ( )
Audible Warning N6 ( )
Electrical System (ti) ( )
Exhaust System cX) ( )
Fuel System (Y) ( )
Glass/Mirrors t() ( 1 •
Body & Sheet Metal (x) ( )
General Present Condition Excellent 0 Good ( ) Moderate ( ) Poor( )
Mileage when Inspected '9 7 L,
I, i3 f, ,'vj /4 /f C.k f� , professing to be a motor vehicle
technician with training in the systems listed above, have evaluated the condition of all
systems and ha e fo1 them_to be in a safe and working condition.
Signature AgencyiCompany
(171) - Ci if - NC 3 iciciA/Ort A, •• rUt' 7.c.clef /I
Phone Address Date
This evaluation will not guarantee future safety and or operability of this ambulance
due to conditions beyond the technician's control.
„hiclo in,p,.,,-, ,,
� 1
P177fIIV COUNTY
Required Basic Life Support Equipment List
/ a/CA
Inspector C ,/t Date
Vehicle Radio Call Sign/ 7Z
Minimum Equipment Required for Basic Life Support Ambulance
Ventilation Equipment
(04 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.
04 Bulb syringe.
(D) 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
ofa 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.
(IQ 750cc bag with transparent masks for children.
(�) 1000cc bag with transparent masks for adult.
(Q Nasopharyngeal airways in adult sizes 24 fr. through 32 fr.
(pq Oropharyngeal airways in adult and pediatric sizes to include: infant, child, small
adult, adult and large adult.
Patient Assessment Equipment
p4 Blood pressure cuffs to include large adult,regular adult, child and infant sizes.
(P( Stethoscope in adult size.
00 Penlight.
Splinting Equipment
(id Lower extremity traction splint.
ft Upper and lower extremity splints.
(p4 Long board with equipment to immobilize the patient from head to heels.
Iil S I:uluire l I.quilnuciu
2 •
14 Scoop,vacuum mattress or equivalent,with appropriate accessories to immobilize
The patient from head to heels.
(b4 Short board or equivalent, with the ability to immobilize the patient from head to
pelvis.
(14 Pediatric immobilization device or adult immobilization device that can be
adapted for pediatric use.
04 Adult and pediatric cervical spine and head immobilization equipment.
Dressing Materials
Bandages-various types and sizes per agency needs and Physician Advisor
protocol.
Spq Multiple dressings(including occlusive dressings),various sizes per ambulance
service requirements, needs and Physician Advisor protocol.
44 Sterile burn sheets.
44 Adhesive tape,per ambulance service requirements,needs,and Physician Advisor
protocol.
(pek Sterile irrigation solution.
Obstetrical Supplies
a Sterile OB kit to include: towels,4x4 dressings,umbilical tape or cord clamps,
scissors,bulb syringe, sterile gloves, and thermal absorbent blanket.
b4 Neonate stocking cap or equivalent.
Miscellaneous Equipment
(cj Heavy bandage scissors, shears or equivalent capable of cutting clothing,belts,
boots, etc.
44 Two working flashlights.
(t4 Blankets and appropriate heat source for the ambulance patient compartment.
Ambulance Service Medical Treatment Protocols.
64_ Oral glucose.
bd. Stair Chair
Communications Equipment
KAll communications equipment shall be maintained in good working order. The
communications equipment must be capable of transmitting and receiving clear
voice communications.
ItI.S Required Iiyuipmint
3
Two-way communications that will enable the ambulance personnel to communicate
with:
(p4 ambulance service's dispatch
(1,4 medical control facility or a physician
04 receiving facilities
mutual aid agencies.
Body Substance Isolation Properly Sized To Fit All Personnel To Include;
K Non-sterile disposable gloves in small,medium,and large sizes,to include a
minimum 1 box of latex free gloves.
(o( Protective eyewear.
aNon-sterile surgical masks.
a Disinfectant spray or wipes for personnel and equipment.
(4 Sharps containers for the appropriate disposal and storage of medical waste and
biohazards.
44. Particulate respirator, N95 type or better.
Safety Equipment
W A set of three(3)warning reflectors.
Ot 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
(fIL Appropriate protective restraints for patients,crew, accompanying family
members, and other vehicle occupants.
(94 Properly secured patient transport system(i.e. wheeled stretcher).
04 Triage tags as approved by the Colorado Department of Public Health and
Environment.
Restraining devices for all items not in a securable cabinet.
14 Two "NO SMOKING-OXYGEN IN USE"signs,one in cab, one in patient
compartment.
Kt_ Reflective vests, coat or equivalent for each member of the crew normally
assigned.
Itl ti IZryui c I I yuiiiink
ApplicatiITKN on or A�bu an ermit
Service Information
Service Name:Snowmass-Wildcat Fire:Protection District
Address: PO Box 6436 Snowmass Village CO 81615
Strect/P-O. City State Zip
Communication:.970-923-2212 970-923-2224 sarthurP,swfpd.com
Voice Fax E-it1ail
Vehicle Information
Radio.Call Sign: M73 License Plate: 789 VKA
VIN: 1 FDAF4HR3AE839794 4X4 Yes ( X ) No ( )
Year: 2010 Make: Ford Type: I
Where will Vehicle be Stationed: 5275 Owl Creek-Road. Snowmass Village, CO
Waiver Request(Include Reason for Request)
John Mele %/ /2 -573
Service Director's Name Signature Date
(Ambulance Inspector Use Only)
Valid Insurance Card Yes No ( )
Valid Registration Card Yes (4 No ( )
Inspection Fee S5'0.001)4 Mechanical Condition Certificate Attached A
Required BLS Equipment List Attached (4
Required ALS Equipment List Attached (vy,
ass Inspection ) Fail ( ) Reason for Failure
Inspector's Nam
$' .tture Si Date
P177IC®
Vehicle Safety and Operability Certification
Ambulance Service. Snowmass-Wildcat Fire Protection District
Vehicle Radio Call Sign 1\1\13
System. Acceptable Non Acceptable Comment
Tires .) ( ) ;eh? iz. , /s)2. g
Wheels Ni ( )
Alitmment f ( )
Suspension '?"/) ( 1 / ` _
Brake System It) C ) tr?J 7 1- SD`J`,
Parkin Brake ) ( )
Headlights- (i0 ( ) 1
Stop/TurnBrake Lts. (4 ()
Visual Warning Lights (i4 ( )
Audible Warning by (
Electrical System (‘/C) ( I
Exhaust System 94 ( ) 1117 uii, ct"ALz P. rrfp( (A-
Fuel:System M ( )
i
Glass/Mirrors CA, it )
•':_ • Body& Sheet Metal OC) ( )
i_
General Present Condition Excellent Good( ) Moderate (, ) Poor( )
Mileage,>vhen Inspected / 9 fly
1, 3 {`icn ; 47- kJ/ , professing to be a motor vehicle
technician with trai ing in the systems listed above, haye eyaluated the condition of all
syste s ani hay- ound them to he in a safe and working condition.
i� �.4 io5V ad MCA
Signature Agency/Company
9-36 -9z -S//a 31 Y 04 Citik a $? '1 y 2< sir- /7
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
COUNTY
Required Basic Life Support Equipment List�l
Inspector fir.rit-4 Date /2//3
Vehicle Radio Call Sin /I 77
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.
b4 Bulb syringe.
(4 House oxygen with a minimum delivery capability of 2 patients simultaneously
through 2 variable flow regulators with capacity at flows of a least I-15 L.P.M.
kr Portable oxygen system with a minimum delivery capability for 1 patient at flows
ofa least 1-15 L.P.M.
(4. 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;
500cc bag with transparent masks for infant and neonate.
fr() 750cc bag with transparent masks for children.
(el 1000cc bag with transparent masks for adult.
(Ogg Nasopharyngeal airways in adult sizes 24 fr. through 32 fr.
(frit Oropharyngeal airways in adult and pediatric sizes to include: infant,child, small
adult, adult and large adult.
Patient Assessment Equipment
frd Blood pressure cuffs to include large adult,regular adult, child and infant sizes.
f4( Stethoscope in adult size.
f.4 Penlight.
Splinting Equipment
(pi' Lower extremity traction splint.
(Pt Upper and lower extremity splints.
(p( Long board with equipment to immobilize the patient from head to heels.
I I ti I:iyuircd I LIuipmcni
2 .
(4 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.
K) Pediatric immobilization device or adult immobilization device that can be
adapted for pediatric use.
Sej Adult and pediatric cervical spine and head immobilization equipment.
Dressing Materials
j Bandages-various types and sizes per agency needs and Physician Advisor
protocol.
€4 Multiple dressings(including occlusive dressings), various sizes per ambulance
service requirements,needs and Physician Advisor protocol.
(pj Sterile bum sheets.
($. Adhesive tape,per ambulance service requirements,needs,and Physician Advisor
protocol.
(Pt 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.
(4 Neonate stocking cap or equivalent.
Miscellaneous Equipment
( Heavy bandage scissors, shears or equivalent capable of cutting clothing,belts,
boots, etc.
(a( Two working flashlights.
(4 Blankets and appropriate heat source for the ambulance patient compartment.
(P9 Ambulance Service Medical Treatment Protocols.
(9( Oral glucose.
(4 Stair Chair
Communications Equipment
(p¢ All communications equipment shall be maintained in good working order. The
communications equipment must be capable of transmitting and receiving clear
voice communications.
ISIS Rcyuind Lquilmicnt
3
Two-way communications that will enable the ambulance personnel to communicate
with:
(P(Q ambulance service's dispatch
kd medical control facility or a physician
(t() receiving facilities
VI 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.
(4 Protective eyewear.
(p4 Non-sterile surgical masks.
(pa' Disinfectant spray or wipes for personnel and equipment.
Sharps containers for the appropriate disposal and storage of medical waste and
biohazards.
(oc Particulate respirator,N95 type or better.
Safety Equipment
(pt A set of three(3)warning reflectors.
(pj. 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
(p( Appropriate protective restraints for patients, crew, accompanying family
members, and other vehicle occupants.
(p4 Properly secured patient transport system(i.e.wheeled stretcher).
II Triage tags as approved by the Colorado Department of Public Health and
Environment.
(ea Restraining devices for all items not in a securable cabinet.
(' Two"NO SMOKING-OXYGEN IN USE"signs,one in cab,one in patient
compartment.
(y4 Reflective vests, coat or equivalent for each member of the crew normally
assigned.
131•S Itryuircd It tiihmcnl
COUNTY
Required Advanced Life Support:Equipment List
Inspector Cv \-y Date h�S�3
Vehicle Radio Call Sign" /'17,7
Minimum Equipment.Requirement for Advanced Life,Support Ambulances
(pd All Equipment Listed In BLS Equipment list
Ventilation Equipment
(4 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.
04. Laryngoscope and blades, straight, and/or curved of sizes 0-4.
(pQ Adult and pediatric magill forceps.
Oct End tidal CO2 detector or alternative device, approved by the FDA, ibr
determining correct tube placement.
Patient Assessment Equipment
M. Portable,battery operated cardiac monitor- defibrillator With strip chart recorder
and adult and pediatric EKG electrodes and defibrillation capabilities.
(4 Pulse oximeter with adult and pediatric sensors.
(M Electronic blood glucose measuring device.
intravenous Equipment
r\ Adult and pediatric intravenous solutions and equipment per
Physician Advisor protocol.
(4 Adult and pediatric intravenous arm boards:
Pharmacological Agents
p Pharmacological agents and delivery devices per Physician Advisor protocol..
(4 Pediatric"length based"device tier sizing drug dosage calculations and sizing
equipment.
As Service Director for Snowmass-Wildcat Fire Protection, 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.
11
John Mete. �r 7/7/1,-/-- /2-5--/
Service Director's-Name Signature Date
,`.,'.SRcgiuircciI`.: c+« : ; ;
Application� Am u al nee Permit
Service Information
Service Name: 13A5ALC 4 PA'-At F%RIy PwoTEcnO r( AIsTWI er
Address: loan '3w nu cr-tROONOA\E co £316t-3
Street/P.O. City Slate 'Lip
Communication: 'rib-toy-0615 q-le-104-061,5 rcorneli fksdbrtc4l't-R-r ..ory
Voice Fax E-Mail
Vehicle Information
Radio Call Sign:M LI ( License Plate:_0-ii)13N F
VIN: 4X4 Yes (X) No ( )
IFOwc12PO6EbG 1HS'3
Year: -Lc CI 6 Make: Fvfab Type: I
Where will Vehicle be Stationed: 5-1 na es( I-I 1
Waiver Request(Include Reason for Request)
•
g C-• NR I. CORN S :..�..e-.. R 11 u< 1
Service Director's Name ignalure Date
(Ambulance Inspector Use Only)
Valid Insurance Card Yes No ( )
Valid Registration Card Yes No ( )
Inspection Fee$50.00 ((Mechanical Condition Certificate Attached ,
Required BLS Equipment List Attached
Required ALS Equipment List Attached •
Pass Inspectian'6C11 Fail( ) Reason for Failure
ff ��
el-k- %SNSC-mil e t1PSJ13
Inspector's Name Signature Date
I
P177flig COURT,"
Vehicle Safety and Operability Certification
Ambulance Service 3nsnW� ���� C-i2 V`'z'° r 'Tto3 tc:It
Vehicle Radio Call Sign N e-p le- 41
System Acceptable Non Acceptable Comment
Tires (4 ( )
Wheels (v( ( )
Alignment (12 ( )
Suspension (4' ( )
Brake System ( )
Parking Brake (V( ( )
Headlights (yr ( )
Stop/Turn/Brake Lts. (4 ( )
Visual Warning Lights (4' ( )
Audible Warning (y4 (
Electrical System (v't' ( )
Exhaust System (4' ( )
Fuel System ('( ( )
Glass/Mirrors ( )
Body& Sheet Metal ('} (
General Present Condition Excellent(v( Good ( ) Moderate( ) Poor( )
Mileage when Inspected (>01‘09
I, GA'21 '1,-,s-71" 2.6 EtZ ,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.
I3A k*
S4
Signature Agency/Company
cflv.-1o4-00 S \cgq'rui-Pr We CAA;z)aunclnie Co. 81623 \0/30113
Phone Address Date
This evaluation will not guarantee future safety and or operability of this ambulance
due to conditions beyond the technician's control.
\ .hir1, Ins�i�rli�m
COLORADO AUTO INSURANCE IDENTIFICATION CARD
COMPANY NAME,ADDRESS:.NAIL NO.
NERICAN AI.TEMWTIVE INSURANCE CORPORATION
555 College Road East, Princeton, NJ 08543-5241
19720
an authorized Colorado Insurer has Issued a policy ol automobEe Rabin),Insurance providing coverage for bodily
Injury.property damage Insurance In at least the minimum amounts prescAed by Colorado Len,to:
INSURED NAME8 ADDRESS
BASALT MD RURAL FIRE PROTECTION
DISTRICT
1089 JW DRIVE
CARBON13818, CO 81623-0000
•
MUCK NUMBER EFFECTIVE DATE DPIMTIGN DATE
VFISTR2061681 01-01-2013 01-01-2014
IAA(=/MWEL YEAR MIME IDENTIFICATION NUMBER
FORD N t:ANCE AL.S 2006 1FIXFF37P06ED67453
INSURANCE AGENT/BROKER
VHS .
183 Leader Heghls Road
York PA 17405
(117)7410911
. . SEE REVERSE SIDE UNWORN RI321a(Ed.7.03)
•
COLORADO REGISTRATION/OWNERSHIP TAX RECEIPT ..
TYPE PLATE - TABNAL " 'VIN - • B
PAS-CNY 078BHF 078BHF 1FDWF37P06ED67453 • PI
•
TITLE YR MAKE BODY CWT/PAS • T/C FLEETO PREV
44E514379 2006 FOR AM 119 • 4446
PUR.DATE PUR.PRICE ORIGINAL TAXABLE VALUE BUS.DATE COO UI
10/04/2006 127769.00 108,603 10/19/2006 44 R !
EM. FEE PRIOR O.T. OWN TAX LIC.FEE TITLE FEE OTHEI
0.00 0.00 0.00 3.26 7:20
• RID TAX COUNTY TAX CITY/DIST TAX STATE TAX SPECIALFEE
0.00 0.00 01.00 0.00
0.00.
UNIT/ .�SVPY:p. • s s MILES HI GVW HC DATE
• OWNER NAME/MAILING ADDRESS
BASALT AND RURAL FIRE
PROTECTION DISTRICT
1089 J W DR
SIGNK
CARBONDALE CO 81623 REQUI
ON RE\
• SIDE.
VALIDATION •
TOTAL
•
PAID EAGLE •01 10/19/2006 103047MKZ B03 Y 10.4
MOTOR VEHICLE INSURANCE IS COMPULSORY IN COLORADO,NON-COMPLIANCE IS A MISDEMEANOR TRAFFIC OF
•
•
HMV COUNTY
Required Advanced Life Support Equipment List
Inspector at C- VvA-N SAN Date U)2-d 13
Vehicle Radio Call Sign M t-(
Minimum Equipment Requirement for Advanced Life Support Ambulances
frg All Equipment Listed In BLS Equipment list
Ventilation Equipment
1..7P 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.
Y0 Laryngoscope and blades, straight, and/or curved of sizes 0-4.
Adult and pediatric magill forceps.
`f f End tidal CO2 detector or alternative device,approved by the FDA,for
determining correct tube placement.
Patient Assessment Equipment
F ' Portable,battery operated cardiac monitor- defibrillator with strip chart recorder
and adult and pediatric EKG electrodes and defibrillation capabilities.
..fl Pulse oximeter with adult and pediatric sensors.
'(?4, 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
'Tfi Pharmacological agents and delivery devices per Physician Advisor protocol.
'l " 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.
R1Ca-141st] CpRt4 at t4r KL,L..ri.,.tYklru....e loft ttZ
Service Director's Name Signature Date
Al S Required Equipment
PITKJNCCOUATY
Required Basic Life Support Equipment List
Inspector a IL- ti-AN S E74 Date if)2-0
Vehicle Radio Call Sign M y I
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.
c>if% Bulb syringe.
-(749 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.
pep Portable oxygen system with a minimum delivery capability for 1 patient at flows
of a least 1-15 L.P.M.
96 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;
c)47 500cc bag with transparent masks for infant and neonate.
S) 750cc bag with transparent masks for children.
1000cc bag with transparent masks for adult.
( Nasopharyngeal airways in adult sizes 24 fr. through 32 fr.
) q Oropharyngeal airways in adult and pediatric sizes to include: infant, child, small
adult, adult and large adult.
Patient Assessment Equipment
$1 Blood pressure cuffs to include large adult, regular adult, child and infant sizes.
Stethoscope in adult size.
h Penlight.
Splinting Equipment
r) Lower extremity traction splint.
pc) Upper and lower extremity splints.
4taa Long board with equipment to immobilize the patient from head to heels.
I{I S Requited) I guihmrni
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.
'C' Pediatric immobilization device or adult immobilization device that can be
L adapted for pediatric use.
Adult and pediatric cervical spine and head immobilization equipnient.
Dressing Materials
Bandages-various types and sizes per agency needs and Physician Advisor
protocol.
y) Multiple dressings (including occlusive dressings),various sizes per ambulance
service requirements,needs and Physician Advisor protocol.
le Sterile bum sheets.
Y
a Adhesive tape,per ambulance service requirements,needs,and Physician Advisor
protocol.
7° 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.
N Neonate stocking cap or equivalent.
Miscellaneous Equipment
i ' Heavy bandage scissors, shears or equivalent capable of cutting clothing,belts,
boots, etc.
cc) Two working flashlights.
( Blankets and appropriate heat source for the ambulance patient compartment.
'" ,,d) Ambulance Service Medical Treatment Protocols.
> Oral glucose.
Stair Chair
Communications Equipment
gig All communications equipment shall be maintained in good working order. The
communications equipment must be capable of transmitting and receiving clear
voice communications.
ISI l Rcquin l liquipmeni
I
3
Two-way communications that will enable the ambulance personnel to communicate
with:
(29 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;
9 Non-sterile disposable gloves in small, medium, and large sizes,to include a
minimum 1 box of latex free gloves.
(iGl Protective eyewear. j
K2 Non-sterile surgical masks.
pr Disinfectant spray or wipes for personnel and equipment.
()c)) Sharps containers for the appropriate disposal and storage of medical waste and
biohazards.
I Particulate respirator,N95 type or better.
Safety Equipment
'(() A set of three(3)warning reflectors.
..0 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
( j) Appropriate protective restraints for patients, crew, accompanying family
members,and other vehicle occupants.
`44) Properly secured patient transport system (i.e.wheeled stretcher).
(y9 Triage tags as approved by the Colorado Department of Public Health and
Environment.
(V) Restraining devices for all items not in a securable cabinet.
7 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.
10 S I:Hulled I`.ounimem
Applica ion f o1rVAmbAmbulance mice V rmit
Service Information
Service Name: 13A.SALT4" RyRtPL PRCTFCloN DlSTRlcr
Address: 1089 W ORtVE. CA-Rtaort0ALE Co 816A-3
Strect/P.O. City Stale Zip
Communication: g10-104-Ob'}5 411o..goy-DtL5 rCorne,tit,sAbeisctl•Wlre_.c•r1
Voice Fax E-Mail
Vehicle Information
Radio Call Sign: M Li° License Plate: 131411K
VIN: 4X4 Yes (X) No ( )
I68 K341y9El41139
Year: 2.nay Make: eNEV Type: I
Where will Vehicle be Stationed: 5'1-tvrot.( 4 4
Waiver Request(Include Reason for Request)
FIc{-I)FRA CoRIYELtt.1S £.+1. w4R Led—oLx2 .. ILIo9IIS
Service Director's Name Signature Dale
(Ambulance Inspector Use Only)
Valid Insurance Card Yes VP No ( )
Valid Registration Card Yes r No ( )
Inspection Fee SS0.00X3 Mechanical Condition Certificate Attached-)
Required BLS Equipment List Attached'
Required ALS Equipment List Attached
Pass Inspection Fail ( ) Reason for Failure
1 c. �-/koJ S 2 _ It]2-S-1
13
Inspector's Name Signature Date
I I
PITKINCOURT?
Vehicle Safety and Operability Certification
Ambulance Service BAS A\-1—'3•Ropa\ ttvte: Przc5 -c.C-C'1°f1 l�tS rz C .
Vehicle Radio Call Sign M e-n\Q, RC)
System Acceptable Non Acceptable Comment
Tires (9' (
Wheels (V)7 ( )
Alignment ("r ( )
Suspension (✓f ( )
Brake System (. ( )
Parking Brake (` /t/� ( )
Headlights (mil ( )
Stop/Turn/Brake Lts. (vY' ( )
Visual Warning Lights (Yr ( )
Audible Warning (V ( )
Electrical System ( )
Exhaust System (v} ( )
Fuel System (4i ( )
Glass/Mirrors ((L.< ( )
Body& Sheet Metal (v1 ( )
General Present Condition Excellent(14Z Good( ) Moderate( ) Poor( )
Mileage when Inspected 3 3 '1.3/
GA(el Les—v Z�' Lr ,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.
'gASA \ ' it2E
Signature Agency/Company WV3 Q'7U._ ta4 -DENS loses( cni.%72WC. ( r_.�ritckt`z c `
Phone Address CLA3 Date
This evaluation will not guarantee future safety and or operability of this ambulance
due to conditions beyond the technician's control.
\ cluck In;hir.li n
COLORADO AUTO INSURANCE IDENTIFICATION CARD
CWPANy NAME,ADDRESS 8 WC NQ .
AMERICAN ALTERNATIVE INSURANCE CORPORATION '.
5
•
55 College Road East, Princeton, NI 08543-5241
19720r ",
an authorized Co!omdo insurer has i«uod a poly of outomcbde liability Insurahca providing iovorage for bodily
injury,property damage ineuranae in at leant the minimum amounts presribed by Colorado Law,to:
NSUR®NAME 8 ADDRESS •
BASALT AND RURAL FIRE PROTECTION
DISTRICT
1089 .771 DRIVE "
•
CARBONDALE, CO 81623-0000 •
PCUCY NUMBER EFFET rVt DATE E71+ViATCN DATE
VPTSTR2061681 01-01-2013 01-01-2019 •
MN(E/MXE. YEAR VEIIGIE mans ICATga■UMBEE
CHEVY AMBULANCE ALS 2004 13E3X34144E142934
INSURANCE AGENT/BROKER
VRS
183 taader Heights Road
York,PA 17405
(717)741-0911
•
SEE REVERSE SIDE UNIFORM R1321 a(Ed.7-03)
•
•
•
•
•
•
•
•
PITKIN COUNTY
Required Advanced Life Support Equipment List
Inspector t(k "1\A-Cel‘i Date (\ J 2417
Vehicle Radio Call Sign PA `-f
Minimum Equipment Requirement for Advanced Life Support Ambulances
r All Equipment Listed In BLS Equipment list
Ventilation Equipment
l�Q 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.
cif Laryngoscope and blades,straight, and/or curved of sizes 0-4.
(>), Adult and pediatric magill forceps.
ket End tidal CO2 detector or alternative device, approved by the FDA, for
determining correct tube placement.
Patient Assessment Equipment
Pc 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.
rElectronic blood glucose measuring device.
Intravenous Equipment
In 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.
Zjcb Pediatric"length based"device for sizing drug dosage calculations and sizing
I 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.
RICHI4-Rh Cortwer IUS CAS .\ Rtrs .aC � .. , 11.10,1
Service Director's Name Signature Date
ALS Required Equipment
1
PITIUI1V COUNTY
Required Basic Life Support Equipment List
Inspector i.5262-( HIAini c U Date \A )2C) 6
Vehicle Radio Call Sign Pi J
Minimum Equipment Required for Basic Life Support Ambulance
Ventilation Equipment
Q 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 ft. through 14 fr.
Bulb syringe.
ze 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/21 mm
fittings in the following sizes;
500cc bag with transparent masks for infant and neonate.
(�p 750cc bag with transparent masks for children.
1000cc hag with transparent masks for adult.
` ) Nasopharyngeal airways in adult sizes 24 fr. through 32 fr.
p Oropharyngeal airways in adult and pediatric sizes to include: infant, child, small
adult, adult and large adult.
Patient Assessment Equipment
XD Blood pressure cuffs to include large adult, regular adult, child and infant sizes.
Stethoscope in adult size.
}` Penlight.
Splinting Equipment
*<V Lower extremity traction splint.
liCP Upper and lower extremity splints.
(.)- Long board with equipment to immobilize the patient from head to heels.
Itl.S Required t{yuilnncnl
2 •
0 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.
NJ Adult and pediatric cervical spine and head immobilization equipment.
Dressing Materials
(p Bandages-various types and sizes per agency needs and Physician Advisor
protocol.
KO Multiple dressings(including occlusive dressings),various sizes per ambulance
service requirements,needs and Physician Advisor protocol.
14 Sterile bum sheets.
Adhesive tape,per ambulance service requirements,needs,and Physician Advisor
protocol.
t7Sterile irrigation solution.
Obstetrical Supplies
keD Sterile OB kit to include: towels,4x4 dressings,umbilical tape or cord clamps,
C scissors,bulb syringe, sterile gloves, and thermal absorbent blanket.
Neonate stocking cap or equivalent.
-
Miscellaneous Equipment -
t" 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.
VI Ambulance Service Medical Treatment Protocols.
?r Oral glucose.
G" Stair Chair
Communications Equipment
e All communications equipment shall be maintained in good working order. The
communications equipment must be capable of transmitting and receiving clear
voice communications.
131.5 1,t coked Equipment
3
Two-way communications that will enable the ambulance personnel to communicate
with:
1 ambulance service's dispatch
k0 medical control facility or a physician
pl. receiving facilities
lyfr mutual aid agencies.
Body Substance Isolation Properly Sized To Fit All Personnel To Include;
Vii Non-sterile disposable gloves in small, medium, and large sizes, to include a
minimum 1 box of latex free gloves.
0 Protective eyewear.
pNon-sterile surgical masks.
`(ti Disinfectant spray or wipes for personnel and equipment.
rip Sharps containers for the appropriate disposal and storage of medical waste and
biohazards.
`N 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.
(`e)) Child safety seat or equivalent
. Appropriate protective restraints for patients, crew, accompanying family
members, and other vehicle occupants.
eye, Properly secured patient transport system (i.e. wheeled stretcher).
"' Triage tags as approved by the Colorado Department of Public Health and
Environment.
Qa) Restraining devices for all items not in a securable cabinet.
'r 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.
It Required I[yuil?mrnl
Application n or Ambn aTnce�ermit
Service Information
Service Name: BA $PrLT ' RuP.v%-L F' -Erto-rec"lor( bvcr tct
Address: tob'l iWYoRW CA-g-B°N DA ite to 81623
Street/P.O. City Stale Zip
Communication: 910-109 ob`j5 tic-1u4-061,c rcorhe-At(As&in4 S el IARIe.ol'Q
Voice Fax E-Mail
Vehicle Information
Radio Call Sign:M 4v License Plate: coat MO(S
YIN: . . . 4X4 Yes (X) No ( )
IFhunprtiC A13294
Year: you 2 Make: r-o R A Type:_I
Where will Vehicle be Stationed: sri}T1ON 4 Z
Waiver Request(Include Reason for Request)
RIcotacRrs Cop-iYEI \LAS gLa.-23.4-A RLOA-nnll-,LA 0401113
Service Director's Name Signature Date
(Ambulance Inspector Use Only)
Valid Lrsurance Card Yes No ( )
Valid Registration Card Yes No ( )
Inspection Fee$50.000 Mechanical Condition Certificate Attached( )
Required BLS Equipment List Attached
Required ALS Equipment List Attached y2
Pass Inspection} Fail( ) Reason for Failure
Mt C- \tAA5e-14 C. 91____. Iil?s1!3
Inspector's Name Signature Date
1
PIT7KINCOUNTY
Vehicle Safety and Operability Certification
Ambulance Service RASA cc 1Zco,4 2 E Trza its i 2icT
Vehicle Radio Call Sign Ihte,o i c 9 a
System Acceptable Non Acceptable Comment
Tires (4 ( )
Wheels ()
Alignment (ti ( )
Suspension ( 1 ( )
Brake System (4. ( )
Parking Brake (rX ( )
Headlights (r" ( )
Stop/Turn/Brake Lts. (4. ( )
Visual Warning Lights(t ( )
Audible Warning (4' (
Electrical System (+- ()
Exhaust System 0"1 ( )
Fuel System (14 (
Glass/Mirrors (
Body& Sheet Metal p{ O
General Present Condition Excellent (t Good ( ) Moderate( ) Poor( )
Mileage when Inspected °R C1;,5 6 G
I, &A Rif L L)T zE l C . , 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.
-cam c e2- e—
.l�fl��a t� men
Signature Agency/Company
V704-56rl-f \oSty-s4t-Powe- LAroDvAnke Cz s aS713
I
Phone Address Date
This evaluation will not guarantee future safety and or operability of this ambulance
due to conditions beyond the technician's control.
will c In,ltcrut
t �a.(DIC. {2
COLORADO AUTO INSURANCE IDENTIFICATION CARD •
COMPMY NAME.ADDRESS 8 NNC NO
AMERICAN ALTERNATIVE INSURANCE CORPORATION
555 College Road East, Princeton, NI 08543-5241
19720
an auforhod Colorado Insurer has Sued a polloy d automobile Iahfy Insurance pto,451ny coverage for bodily
Injury,property damage insurance In at Mal the minimum amounts pteslbed by Colorado Law,to:
INSURED NAME 8 ADDRESS
BASALT AND RURAL FIRE PROTECTION
DISTRICT
1089 .BI DRIVE
CARBONDALE, CO 81623-0000
ROIICY NUMBER EFFECTIVE DATE EW'RATION DATE
VFISTR2061681 01-01-2013 01-01-2014
MME/MECEL YEAR VEHICLE IDFRUFICATn\NUMBER
FORD AMBULANCE ALS 2012 1FDUF4NT3CEA13284
INSURANCE AG134T/BRO(ER
VFIS
183 Leader Heights Road
York,PA 17405
(717)7410811
SEE REVERSE SIDE UNIFORM RI321a(Cd.7.03)
COLORADO REGISTRATION/OWNERSHIP TAX RECEIPT
TYPE PLATE TABNAL VIN EXPIRE
• PAS-CNY 621HOK 621HOK 1FDUF4HT3CEA13284 PERM.
TITLE YR MAKE BODY CWT/PAS T/C FLEETS FUEL PREY EXP
44E597515 2012 FOR AM 128 4446 D
PUR.DATE PUR.PRICE ORIGINAL TAXABLE VALUE BUS.DATE CO 0 UR/CODE
11/09/2011 157583.00 133,945 12/07/2011 44 R 9999
EM. FEE TITLE FEE PRIOR 0.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 TAX CITY/DIST TAX STATE TAX SPECIAL FEE OTHER FEE
0.00 0.00 0.00 0.00 0.00 0.00
UNIT g''QQ``xx ,^`r1MILES HI GM HE DATE
OWNER NAME/MAIUNG ADDRESS 'FEES IN BOLD INCLUDED IN NC FEE
BASALT AND RURAL FIRE �'w"/ 11ll
PROTECTION DISTRICT • 1 _ IX SIGNATURE
1089 J W DR 7 REQUIRED
CARBONDALE CO 81623 ON REVERSE
SIDE.
VALIDATION TOTAL
PAID EAGLE 01 12/07/2011 121923LLC B03 Y 10.98 PI
MOTOR VEHICLE INSURANCE IS COMPULSORY IN COLORADO,NONCOMPLIANCE IS A MISDEMEANOR TRAFFIC OFFENSE
•
•
•
•
' 1
PITICIN COUNTY
Required Basic Life Support Equipment List
Inspector EQ-.1 c—N'A-N c Date \ i 125113
Vehicle Radio Call Sign M `f 2
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 ft. through 14 fr.
' Bulb syringe.
'p 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.
ka 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
[[/y pediatric sizes.
Bag-valve mask resuscitators with oxygen reservoirs and standard 15mm/21mm
fittings in the following sizes;
y5 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 fr.
Oropharyngeal airways in adult and pediatric sizes to include: infant, child, small
adult,adult and large adult.
Patient Assessment Equipment
1"" Blood pressure cuffs to include large adult,regular adult, child and infant sizes.
;per Stethoscope in adult size.
'(. Penlight.
Splinting Equipment
Lower extremity traction splint.
Upper and lower extremity splints.
Long board with equipment to immobilize the patient from head to heels.
Ill ti ICAmity(' I'yuipmciln
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
C pelvis.
(D 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
la 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.
`ir Sterile irrigation solution.
Obstetrical Supplies
.Y"' Sterile OB kit to include: towels,4x4 dressings, umbilical tape or cord clamps,
scissors,bulb syringe,sterile gloves, and thermal absorbent blanket.
igko Neonate stocking cap or equivalent.
• Miscellaneous Equipment -
141) 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.
c) Oral glucose.
' p Stair Chair
Communications Equipment
r j� All communications equipment shall be maintained in good working order. The
c communications equipment must be capable of transmitting and receiving clear
voice communications.
J I S Pequirrtl I'.gtiipmctit
3
Two-way communications that will enable the ambulance personnel to communicate
with:
la ambulance service's dispatch
IN� medical control facility or a physician
bo) receiving facilities
mutual aid agencies.
Body Substance Isolation Properly Sized To Fit All Personnel To Include;
10 Non-sterile disposable gloves in small, medium, and large sizes,to include a
minimum 1 box of latex free gloves.
sProtective eyewear.
r Non-sterile surgical masks.
eDisinfectant 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
(ei 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.
ifry Child safety seat or equivalent
frA Appropriate protective restraints for patients, crew, accompanying family
members, and other vehicle occupants.
Properly secured patient transport system (i.e. wheeled stretcher).
1fl Triage tags as approved by the Colorado Department of Public Health and
Environment.
) 9 Restraining devices for all items not in a securable cabinet.
"(✓h 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.
It S Itcquired I.,Iinii irn,
- PITKJN COUNTY
Required Advanced Life Support Equipment List
Inspector 1C-- R6\/5E Date lk/ 113
Vehicle Radio Call Sign Mee, LP—
Minimum Equipment Requirement for Advanced Life Support Ambulances
�(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 6.0-8.0 per Physician Advisor protocol.
Laryngoscope and blades, straight, and/or curved of sizes 0-4.
(bc)) 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
DPortable, 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.
((CP Electronic blood glucose measuring device.
Intravenous Equipment
, Adult and pediatric intravenous solutions and administration equipment per
Physician Advisor protocol.
0 Adult and pediatric intravenous arm boards.
Pharmacological Agents
4DPharmacological agents and delivery devices per Physician Advisor protocol.
'n 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.
Service Director's Name Signature Date
ALS Required Equipment
Application n f'or Ambulance e Permit
Service Information
Service Name: gmtsA-Ci4 1'c4 -L FIRE rgc-rEvrIort P15 4`T
Address: 1089 '3W DRflE CA-P-8aomb.gtE G,o 81413
Street/P.O. City Stale Zip
Conununication: 910-1104-661'"S `11o'104 -9&2V rtorneliil,s nsgliFir�'°r'I
Voice Fax E-Mail
Vehicle Information
Radio Call Sign: 41 (3 License Plate:_05tB F
VIN: 4X4 Yes (X) No ( )
1FflwF33Fl9 Esg6b 11
Year: 2oao Make: rolSb Type: I
Where will Vehicle be Stationed: $174- tor4 4 3
Waiver Request(Include Reason for Request)
P 1 1-I 14 RCN wRN EU LAS (-LeL-u.e.d 1'1-1.x1 i 13
Senior Director's Name Signature Date
(Ambulance Inspector Use Only)
Valid Insurance Card Yes No ( )
Valid Registration Card Yes? No ( )
Inspection Fee$50.00 Mechanical Condition Certificate Attached
Required BLS Equipment List Attached n)
Required ALS Equipment List Attachedf
Pass Inspection'd9 Fail( ) Reason for Failure
E-)21 VYRNS — e 1 fzsf 13
- - -------------- --
Inspector's Name Signature Date
1
PITICIN COUNTY
Vehicle Safety and Operability Certification
Ambulance Service 7AYA\- a'gotzwl Rene I aotec- to,J %STIR tLT
Vehicle Radio Call Sign M eci tc H 3
System Acceptable Non Acceptable Comment
Tires (W. ( )
Wheels (vY ( )
Alignment (tom ( )
Suspension ( )
Brake System {vY ( )
Parking Brake ( )
Headlights (tom ( )
Stop/Turn/Brake Lts. -(v)' C)
Visual Warning Lights(ts" ( )
Audible Warning ( )
Electrical System (OK ( )
Exhaust System (y' ( )
Fuel System ("Y ( )
Glass/Mirrors (9 ( )
Body&Sheet Metal (t') ( )
General Present Condition Excellent Good( ) Moderate( ) Poor( )
Mileage when Inspected S 0 3 0
I, GAoty ),,ln a-c- e n.. ,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.
BA SAW Citi.e, f e.scv1C
Signature Agency/Company
' P
x'20— nod -0ors ,ogS ^ Druuc. CA tJ , � lre)(tA4(13
Phone Address C-A s(6`.CS Date
• This evaluation will not guarantee future safety and or operability of this ambulance
due to conditions beyond the technician's control.
'chicle H , ❑: ,.
Asps, L(3
COLORADO AUTO INSURANCE IDENTIFICATION CARD
COMPANY NAME,ADDRESS S NAC NQ
AMERICAN ALTERNATIVE INSURANCE CORPORATION
555 College Road East, Princeton, NJ 09543-5241 •
19720
an authorized Colorado Insurer has Issued a poky of automobile liabilly Insurance providing coverage for bodily'
injury,property damage Insuranos In at lead the minim um amounts war-rand by Golaado Law,lo:
INSURED NAME 8 ADDRESS
BASALT AND RURAL FIRE PROTECTION
DISTRICT
1089 J41 DRIVE
CARBONDALE, CO 81623-0000
PCUGY NUMBER EFFECTIVE DATE EXPIRATION DATE
VFISTR2061681 01-01-2013 01-01-2014
MNXE/MCOR. YEAR VEHICLE IDENTIFICATPN NUMBER
FORD AMBULANCE ALS 2000 IFDWF37F1YEB96612
NSURA\CE AGENT/REICHER
YRS
183 Leader Heights Road
York,PA 17405
(717)741-0911
ac REVERSE 61DE UNIFORM R1321a(Ed.7-03)
COLORADb•REOISTRATION/OWNERSHIP TAX RECEIPT
TYPE 'PLATE , ,7ABNA6- , VIN .EXPIRE
LTK-CNY 052BHF . 052BHP ,IFDWF37F1YEB96612 'PERM.
•
TITLE YR MAKE BODY CWT/PAS TIC FLEET/ PREY EXP
44E302803 2000 FOR .!PK 71 4446
• . PUR.DATE PUR.PRICE ;ORIGINAL TAXABLE VALUE :BUS.DATE CO N UR/CODE
04/2572000 85914..00 63,750 01/19/2005 44. 12 9999
€M. FETE PRIOR 0.T. OWN TAX ILIC.FEE TITLE FEE OTHER FEE
. °0.00 0.00 0.00 3.26 0.00 -0,0(
RTD TAX COUNTY TAX CITY/DISTTAX STATE TAX SPECIAL FEE FUR
0,00 0.00 0.00 0.00 • 0.00 D
'UNIT N :, "t933'r 'Nrt MILES HI GVIV HC DATE
• l ° •
•OWNER NAME/MAILING ADDRESS. , •
BASALT-AND RURAL FIRE - 3
I '\��1C
;PROTECTION DISTRICT ' Nd
SIGNATURE
• • - 'REQUIREb
M089 J W DR r 0$REVERSE
•
•
CARRONDALE 'CO 101623 _ • SIDE.,
VALIDATION • • 'WEAL
`TAID `EAGLE 01 01/1-9/2005 083942LLC -R04 Y 3.26 PI
MOTOR VEHICLE INSURANCE IS COIdPULSOBY It COLORADO,NONCOMPLIANCE IS A MISDEMEANOR TRAFFIC OFFENSE
•
•
•
PJ KIN COUNTY
Required Advanced Life Support Equipment List
Inspector OA e I-1 ft\i •cS Date 1 1125)/ 3
Vehicle Radio Call Sign 11A II 3
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.
19 Laryngoscope and blades,straight, and/or curved of sizes 0-4.
(y) Adult and pediatric magill forceps.
tp`
End tidal CO2 detector or alternative device, approved by the FDA, for
determining coned 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.
(yi Electronic blood glucose measuring device.
Intravenous Equipment
(7 • Adult and pediatric intravenous solutions and administration equipment per
Physician Advisor protocol.
Adult and pediatric intravenous arm boards.
Pharmacological Agents
(7) 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 Statc of Colorado and Pitkin County to provide medical care and
transportation of the sick and injured at the Advanced Life Support level.
!Ai C-H W Pfd crrP-rt ELtus 14-1<0vNoA-AL.A. aloq 1 r3
Service Director's Name Signature Date
ALS Required Equipment
PITKIN couivn'
Required Basic Life Support Equipment List
Inspector eg- L 4-Aw Sew Date li I7 e I I 3
Vehicle Radio Call Sign t"\ l( 3
Minimum Equipment Required for Basic Life Support Ambulance
Ventilation Equipment
ND 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.
`o Bulb syringe.
tteP 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.
VP Portable oxygen system with a minimum delivery capability for 1 patient at flows
of a least 1-15 L.P.M.
K) 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;
500cc bag with transparent masks for infant and neonate.
750cc bag with transparent masks for children.
X� p 1000cc bag with transparent masks for adult.
,"� Nasopharyngeal airways in adult sizes 24 fr. through 32
}Y fr.
Y' Oropharyngeal airways in adult and pediatric sizes to include: infant, child,small
adult, adult and large adult.
Patient Assessment Equipment
yj Blood pressure cuffs to include large adult, regular adult,child and infant sizes.
dJStethoscope in adult size.
Penlight.
Splinting Equipment
, Lower extremity traction splint.
Itc Upper and lower extremity splints.
Long board with equipment to immobilize the patient from head to heels.
BLS Required Equipment
J
2
7' Scoop,vacuum mattress or equivalent, with appropriate accessories to immobilize
l The patient from head to heels.
p 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
`(6D Bandages-various types and sizes per agency needs and Physician Advisor
protocol.
r ~ Multiple dressings(including occlusive dressings),various sizes per ambulance
service requirements,needs and Physician Advisor protocol.
69 Sterile burn sheets.
(D 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.
'(ieD Neonate stocking cap or equivalent.
Miscellaneous Equipment
10 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.
,rib Ambulance Service Medical Treatment Protocols.
j Oral glucose.
Stair Chair
Communications Equipment
Iiij) All communications equipment shall be maintained in good working order. The
communications equipment must be capable of transmitting and receiving clear
voice communications.
BLS Required Equipment
,
3
Two-way communications that will enable the ambulance personnel to communicate
with:
rambulance service's dispatch
pmedical control facility or a physician
preceiving,facilities
19 mutual aid agencies.
Body Substance Isolation Properly Sized To Fit All Personnel To Lnclude;
NO Non-sterile disposable gloves in small, medium,and large sizes, to include a
• minimum 1 box of latex free gloves.
kcp Protective eyewear.
'(6a.) Non-sterile surgical masks.
(K) Disinfectant spray or wipes for personnel and equipment.
( j 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.
.r One(1)ten pound (10 lb.)or ts; ve pound(5 lb.) ABC fire extinguishers,
with a minimum of one extinguis er accessible from the patient compartment and
vehicle exterior and having been serviced within previous year per NFPA 10
section 4.
14 Child safety seat or equivalent
(jycY Appropriate protective restraints for patients, crew, accompanying family
members, and other vehicle occupants.
'kg Properly secured patient transport system (i.e. wheeled stretcher).
Oq.) Triage tags as approved by the Colorado Department of Public Health and
III ' Environment.
p-)-. Restraining devices for all items not in a securable cabinet.
Two"NO SMOKING-OXYGEN IN USE"signs, one in cab, one in patient
compartment.
0) Reflective vests, coat or equivalent for each member of the crew normally
assigned.
BLS Required Equipment
1