The URL can be used to link to this page

Home My WebLink Aboutbocc.con.057.2003 LICENSE AGREEMENT NO. 057-2003 PITKIN COUNTY AMBULANCE LICENSE FOR: SNOWMASS-WILDCAT FIRE PROTECTION DISTRICT MEDIC 7, MEDIC 8, MEDIC 9 GRANT OF LICENSE/PERMIT The undersigned, representing the Board of County Commissioners of Pitlcin County, Colorado, do hereby grant a license to the above named applicant to provide ambulance service within Pitkin Connty. This license shall have upon it any restrictions listed below, shall be granted any waivcrs listcd bolt)w, and shall bc valid liar Iht dates listed below, unless revoked by ll~c [h~ard pursuanl I~) Ibc provision ol' Pilkin ('{tartly Resolution No. 87-7 and any applicable laws ,,1' Iht Slate t}l'( 't~h~rath~. I(ESTRICTIONS: WAIVERS GIL~NTED: Fills LICENSE IS VALII) FI/O[~I: lalnlm'y l, 2{,~113 thrtmgh December 31, of 201)3 -x, PPROVED BY 'FILE PITKIN COIJNTY BO,~tRD OF COUNTY OMMISSIONERS ON March 26, 2003 J~l~ Hatfield, Chaivfi~an l~if/kin County Boa~'ofCounty Commisisoners PITKBV COUNTY' APPLICATION FOR AIVlBULANCE SERVICE LICENSE GENERAL INFOI~MATION Ambulance Service Name: ",~-~ ' ,' . Doing Business As: STREET/PO~7~_ ~BOX ~ JC~ C/~' CII'Y I,5 ~'~---[~' TE~;~O~,.~ ' ZiP CODE Omce Conmmnications: VOICE FAX E-MAIL IN[ERNE SERVICE INFORMATIO~ Service Area: /Zd'xI.?~;~T >- . ........... :.~_. ; Service Type: PUBIAC._ ;~__ PRIVAIIi ...... I}I.S Number ofA~nbulances Licenesd: PIIYSICIAN ADVISOR INFORMATION Physiciml Advisor Nmne: Office Address: d'"6'~/ S'IREET/PO BOX CITY/ SfATE ZIP COI)E Office Communications: / ~d ~ ) ~ q- / ~ ~' '~ .... ' - VOICE FAX E-MAll. IN'l ERNET ! hereby certify that the information provided iii this application is Irue to the best of my knowledge and belief and coatains no willful misrepreseutatiou or falsification. Determination that an Ambulance Scrvice License has bccn issued based on false information coustitutes grounds for license revocation, snspension of operations aod possible criminal prosecution. _ , , / · P, ' .~ SERVICE DI~CTOR'S SIGNATURE ~A'I'E ?ItYSICIAN ADVISOR'S SIGNATURE DAFE (FOR EMS COUNCIl. USE ONLY) Date Received: t{l[ 3/ca. _ Ambulmme Permits Attached: EMS Council Comments: ---~' EMS Council Recommendation: ~ ~o ~__a4 o --J-,~,a ~ ca~x.,~ r~ EMS Council Chairperson Signature: ~: :2 ..... ~.~-/ {,,/o _ . _ ItJt~/ / NAME DATE Date Referred to BoCC: BoCC Action: Date: PITKIN COUNTY' APPLICATION FOR AMBULANCE VEtllCLE PERMIT SERVICE INFORMATION Ambulance Service Name: <,/,~W>/?( ' ~ r-~: - ';' ~TREE'ITPO BOX CFFY ~E. ZIP CODE Office Comnmnications: :/'?( 9:?~ .?M2 c.'v,z..,, c/Z"4 222~'. ()',t.:3(?"~('/.'~?: VOICE FAX ' E-MAIL INI ERNI!T VEIIICLE INFORMATION (, ~]IiIssis Year: [~.?g(. Type: I K II Ill ,Ix,l: 5'csy' *.(_(. :~. Make: ._. Insurancc (Oml)a,,y: ~.¢~J{E~(. ~..~ ..... Policy bh,,nl,er: .~?_~ l':xpiratio,,: STRI;ET/PO BOX CITY U S'IA FE ZiP COt)l! RLOUESI FOIl WAIVER (include reason lbr requesU SERVICE DIRECTOR'S SIGNA I'URE I)A[E (FOR AblBULANCE INSPECTOR'S USE ONI.Y) Clear CCIC: Clear NC1C:__ Insurance Card Present: -k/ Permit Fee Attached '<1~- Basic Life Support Required Equipment List Attached ¥ Mechanical Condition Certification Attached ~ Advance Lite Support Provider Required Equipment Certification Attached Comments/Recommendation: INSPECTOR'S SIGNATURE ' POSITION DA FE ,/'? ? PITKIN COUNTY' BASIC LIFE SUPPORT REQUIRED EQUIPMENT LIST MEDICAL EQUIPMENT AND SUPPLIES Diagnostic: -..~ Blood pressure cuffs in large adult, regular adult, child, infaut and neonatal sizes. ~ Stethoscopes in adult and pediatric sizes. ~' Pulse oximeter with adult and pediatric sensors. hnmobilization & Splinting: ~ One lower extremity tractiou splint. ~" Upper and lower extremity splints of any type (vacuum, air, SAM, wire, board, etc.). . ~' _ Long spineboard, vacuum mattress or equivalent with appropriate accessories to immobilize patients l~om head to heels. ~ ..... One orthopedic stretcher (scoop). ._.~_~. Short spineboard, KED or cquivalcnl with appropriate straps lo immobilize patients [ixm~ head lo pclvis. '~.._ Pediatric spincboard or adull spincboard adaplahlc lo pediatric use. 5:~ ..... Adult and pediatric sized head iummbilizatiml equilmlenl lin' each hmg Slfincln~ard and/~u' scoop Stl'UlcIiCl' carried. ...~ .... Rigid cervical immobilizalion collars in lall adult through inlhut sizes. Wound Care: Bmldagcs, including but uot limited to, roller gauze, triangular and elastic per ageucy needs. . Dressings, including but uot limited to, tramna. ABD, gauze, occlusive and baudaids l)cr agcucy uccds. Sterile burn sheets. .... ~ Povidone and alcohol swabs or equivalent. ~ Adhesive tape, including but not limited to, 1" and 2" per agency ueeds. ~' Sterile i~igation solution. Obstetrical Supplies: ~ Sterile OB kit to include: towels, 4x4s, umbilical tape 0r cord clamps, scissors, bulh syringe, sterile blanket ~d sterile gloves. ~ Silver Swaddler and stocking cap or equivalents. Int~ction Control: -~' Exm gloves in small, medium and large sizes. ~' Face and eye shields. -ff Fluid-proof gowns with full length sleeves or equivalent. ~" Disint~ctmlt spray or wipes lbr personnel ~d equipment. Miscellaneous: ~ Oral glucose. ~ Activated ch~coal. ~' Heavy duty bandage scissors or shears capable of cutting clothiug, belts, boots, etc. · ~Spill-proofemesis container with at least 1 liter capacity. ~ universal or separate male and female urinals. ~ Multi-level wheeled gumey ,~ Stair chair or equivalent. ~ Blankets. ~ Patient compa~ment heater. PITlflflt COUI TI/ BASIC LIFE SUPPORT REQUIRED EQUIPMENT LIST SAFETY EQUIPMENT _-;('"- One 2-I/2 lb. or larger ABC lh'e extinguisher, accessible from the patient compartment and baviug been serviced within the last year per NFPA 10 Section 4. ~' One 5 lb. or larger ABC fire extinguisher, accessible l~om outside the vehicle and having been serviced within the last year per NFPA 10 Section 4.. ~' Two "NO SMOKING-OXYGEN IN USE" signs, one in cab and one in patient compartment. ~ Flashlight, 2-D cell equivalent or better with spare bulb and batteries or charger. ~ Set of 3 reflective warning devices. ~ One rellective vest, coat or equivalent lbr each member of the crew normally assigned. ~ At least ooe "SIIARPS" container, clearly labeled and easily accessible in the patient COml~artmcnt. ~ Restraining devices lbr all items not in a securable cabinet ~. ', Audible wanting device (siren) ;vith at Icasl 2 diflbrciit tones. .~'~ Visual warning devices (lights,} with alternating red and/or blue Ilashmg ;~r rolaling visible li'~m~ all qidc:; simultaneously and clear Ilashing or oscillating ;qsiblc l?om ii'ont. C~OMMUNICATIONS EQUIPMENT ..;>~'~ Mobile VIfF radio with appropriate State, Pitkin County and iudividual agency fi'cqucncics. ~'- Mobile UIIF radio with appropriale State, Pilkin County, hospital and individual agency fi'equcticies. Portable radio wilh charger and/or cellular phone [br back-up communicatious wilh dispatch and hospitals. MEDICAL EQUIPMENT AND SUPPLIES Airway: Fixed suction system with ~vide bore tubing, rigid pharyngeal curved suction tip and soft cathcte,' suction tip with sizes from 5 Fr. to 14 Fr. .-,~7" Portable suction system with ;vide bore tubing, rigid pharyngeal curved suction tip and sol't catheter suction tip with sizes t¥om 5 Fr. to 14 Fr. '5''~ Bulb Syringe. ~ Nasopharyngeal airways in pediatric and adult sizes. ~X'~ Oropharyngeal airways in pediatric and adult sizes. -'~ Bite stick or equivalent (oropharyngeal airway). &~' Fixed oxygen system with a ~ninimum storage capacity of 125 cubic feet (M cylinder) and a minimum delivery capability for three patients simultaneously at flows ol'at least 1-15 LPM. -~' Portable oxygen system with a minimum storage capacity of 15 cubic feet (D cylinder) and a minimnm delivery capability for one patient at flows of at least 1-15 LPM. -,V'~ Infant Bag-Valve-Mask with 500cc bag, reservoir and newborn, infimt and child masks. ~ Adult Bag-Valve-Mask with 1000cc bag, reservoir and adult mask. **All mask attaclnnents must be 15mm** ~,/'~ Oxygen masks and cannulas capable of delivering oxygen to adults and inlhnts at flows of at least 1-15 LPM. Mov 05 02 O~:20p Geegor~ R. Balko, M.D. [9701 927-4205 p. ! ~ov IlS O~ 09:00a Sno~mass F~re ~str~ct ~?0923~2~4 p.3 ADVANCED LIFE SUPPORT PROVIDER REQUIRED EQUIPMENT CERTIFICATION REQUIRED ALS EQUIPMEINT 1. All equipmenl and supplies listcd on lhe Basic I.ili: Suppor~ Requh'cd Equipment I..ist. 2, Pedialric diagnoslic cquipmeul, age/wcighffvital signs chart o,d ~ug dosage/equipment size Iisi 3. Adult, pedialfic and nco-natal vascul~ access supplies and equipment ~ authorized in medical protocols approved for Ibis mubul~ce sc~ice. 4 Adult, pcdialric ired uco-uafal endoltacheal intubatitm equipment as aulhotized m medical prol~cols approved tbr this ;mlbulance qervice 5 Cardiac momt~ffdctibrillalor with pmde~' and adull ~d pedialric iBonllOllng, dctitmllalmg ami t}acing Cal>abililies as :mlho~zcd m medical protocols approved li~e this ambulance :~civice 6. l'hmnacological agents anti iuhninix/rali~n equiplneal ~utd supplies as anihorized m medical prc. loofl5 appmued tbf fllis ambulance setwice L Any additional cqol[mlcnt and sub>plies Deeded 1o [mrtBrm other proced,~es as aulhorized m m~ical p~otocols approved for this ianbulancc :;ervicc. As Physician Advi.~or Ibr _, I cerlify thai tiffs ambulance carries the equipment and supplies listed above m~d Incels the minimum reqniremenB, cslablislled by the State of Colorado ~d Pitkin County, Io provide medical cme and I~ansportalion of Ihe sick and injured al the Adv~ced Life Suppo~ level. Provision of Advmced Life Supra is limited as described in 3-CCR-713-6, Section 4 "Medical Acts AllDwed EMTs and Paramedics." ~IAN ADVISOR'S S1GNA~ -- COLO~ MEDICAL LICENSE NUMBER DA1 E ? PITKIN COUNT VElilCLE SAFETY AND OPEI~BILIT¥ CERTIFICATION Ambulance Service Name: ~'.i"~. ~,'~::,55 .'?i: q~5'~3License Plate: '7"?/-6fY/ Ambuhmce Number: ,.~,~ ,t~ ~ SYSTEMS ACCEPTABLE NOT ACCEPTABLE COMMENTS Wheels & Tires Steering Alignment Suspension ~/' .................................... Service Brakes I:'arking Brake ........... :: ' l)riving Ligbls Visual Warning Systems Audible Warning Systems ? .......................... Electrical System Exhausl System -- Fuel System .... Glass, Mirrors Body & Sheet Metal I, 6/d~.~ C'/~,/~.~ , professing t2 be a motor vehicle mechanic with tr. aining in all of the systems listed ;boveq l-~e evaluated thc cm~dition of these systems on the ambulance indicated above and have determined this ambulahce to be in safe operating condition. This evaluation does not warrantee thc future sat~ty and/or operability of this mnbulance due to conditions beyond my control. AGENCY/COMPANY PIIONE NUMBER DAlE TYPE PLATE TABNAL - VIN EXPIRE PAS- REG 471GpI --~iTi~ ......... F062513 1FDWF37F32EA13220 04/2003 MA~(E 57E195420 2002 FOR ~ 110 C PUR DATE PUR, PRICE 03/27/2002 87050.00 co, O~Cd~ ~' f~i-f~ ....... 73, 992 04/17/2002 57 U 01SV 0.00 EX ~X RTD TAX COUNTY tAX ~ifif/om~f YA~ .... ~ .... 9.5 0 000 .... · 0.00 D BNO~ss WILDCAT 'FIRE PROTECTION DIST P.O. BOX 6436 ._SN~ASS VLG CO 8 [6 1.5 PAIl) PI'I'Kf[N O0 04/17/2002 12][SH'['~B B(}J A 9. iL i.. - - 50 Ph COMp~¥,~UM~!~:n Isr~rEi CO INSURANCE IDENTIFICATION CARD 0983 GOMPAI~y POLiCy N(IMSEN MCNeil & Company SSC100365E ~F~C nv~ o~r~ 03/23/2002 ~xpm~ no~ o~ t~ Y~A~ 0312312003 ~002 MAK~'MODEL VEHICLE JOENT~FICATiON ~;UMBER FordlF350 Ambul IFDWF37F32EA~3220 ....... · ,.~n ~SUrince Se~lces 2260 So. Xanadu Way ~ 280 {303)368.5~57 AUrora, CO 80014 iNSURED SnOWmass-Wiidcat Fire ProtecSon District S275 Owl Creek Road 8nowmass ~llage, CO 81615 SEE IMPORTANT NOTICE ON REVERSE SIDE PITKIIV CO U. / APPLICATION FOR A3IBULANCE VEHICLE PERMIT SERVICE INFORMATION Ambulance Service Name:.~;)?2%-~,q,7~ 5,~ ' /~ '?'. :,~,, '~' ' Office Co~ications: ~7D-~'2.~'221Z ~/7~"~Z~"222~ ~([~/~;.dt~ VOICE FAX ~M~L ~ :mc[e Desi~ation'//~/,~ 7 License Plate:](?~/~ ~ = ' ' / ~ ~ Chassis Ye~: //9'5 Make:( 71?},[l~fi Type: [ .5 II III ~ 4x4: yes ~ no [nsumce Comp=y://)'~4,i/[ a'i~d. ['~9'lq/.~(?t~, ~ Policy Nmber: ~ .7 ,F..~ Expiration:,=~/~ VeNcle Location:: S~l~ BOX C~ STA~ ZIP CODE -')~OUEST FOR W.~TR (include re,on for request) 'Z-- SERVICE DIRECTOR'S SIGNATURE DATE (FOR AMIIULANCE INSPECTOR'S USE ONLY) Clear CCIC:__ Clear NCIC:. Insurance Card Present: ..~--- Registration Card Present: 4-'-' Permit Fee Attached ~ Basic Life Support Required Equipment List Attached '4"-- Mechanical Condition Certification Attached ~ Advance Life Support Provider Requi.red Equipment Certification Attached Comments/Recommendation: U~,~ECI'OR'S SIGNATURE POSITION DATE PITKIN COUNTY' BASIC LIFE SUPPORT REQUIRED EQUIPMENT LIST MEDICAL EOUIPMENT AND SUPPLIES Dia~gt~stic: "~ Blood pressure cuffs in large adult, regular adult, child, infant and neonatal sizes. ~'Stethoscopes in adult and pediatric sizes. Pulse oximeter with adult and pediat,'ic seosors. hmnobilization & Splinting: <9~-- One lower extremity traction splint. -~', Upper and lower extremity splints ol'any type (vacuum, air, SA/vi, wire, board, etc.). ~.~___ Long spineboard, vacuum mattress or equivalent with appropriate accessories to immobilize patients from head to heels. 5)5_~_ One orthopedic stretcher (scoop). -~. ~___ Short spiueboard, KED or equivalent with appropriate straps to immobilize patients Ii'om bead Iv poi :'-~_i~i.i. Pediatric spit]cboard or adult spineboard adaptable to pediatric use. .:~. .... Adult and pediatric sized head immobilization equil>meet lbr each l~mg spinel~oard alld/ol' ,jr:oilIl :;ll't~h:her carried. ~'~' Rigid cervical inmmbilizalion collars in tall adull lhrough inlhnt sizes. Wound Care: >'"' Bandages, including but not limited to, roller gauze, triaugular aud elastic per agency needs. ~'- Dressiugs, including but m)t limited to, trauma, ABD, gauze, occlusive and bandaids pcr agellcv needs. ::w-" Sterile burn sheets. ' ¢ Povidoue and alcohol swabs or equivalent. _~_ Adhesive tape, including but not limited to, 1" and 2" per agency needs. Sterile irrigation solution. Obstetrical Supplies: '~ Sterile OB kit to include: towels, 4x4s, umbilical tape Or cord clamps, scissors, bulb syringe, sterile blanket and sterile gloves. ~V"~ Silver Swaddler and stocking cap or equivalents. lntbction Control: -~'-- Exam gloves in small, medium and large sizes. ~ Face and eye shields. er--' Fluid-proof gowus with full length sleeves or equivalent. ~ Disinfectant spray or wipes for personnel and equipment. Miscellaneous: ~ Oral glucose. 4''''r Activated charcoal. ~ Heavy duty bandage scissors or shears capable of cutting clothing, belts, boots, etc. Spill-proof emesis container with at least I liter capacity. universal or separate male oa~d felnale urinals. ,-:~.i Multi-level wheeled gurney ~-- Stair chair or equivalent. ~'- Blankets. ~ Patient compart~nent heater. / PITKIN COUNTY' BASIC LIFE SUPPORT REQUIRED EQUIPMENT LIST SAFETY EQUIPMENT -4-'~- One 2-1/2 lb. or larger ABC lire extinguisher, accessible from tile patient comparmmnt and baying been serviced within the last year per NFPA 10 Section 4. ~ One 5 lb. or larger ABC lire extinguisher, accessible l~om outside the vehicle and baying bccn serviced within the last year per NFPA 10 Section 4.. ~ Two "NO SMOKING-OXYGEN IN : signs, one in cab and one in patient comparmmat. USF" ~ Flasbligl~t, 2-D cell equivalent or belier with spare bulb and batteries or charger. Set of 3 rellective warning devices. _~ One rellective vest, coat or equivalent lbr each member of the crew normally assigned. '~ At least one "SHARPS" container, clearly labeled and easily accessible in the patient comlgarlment. _~_~ Restraining devices for all items not in a securable cabinet E MEkI G E N~..~ARN 1 ~ h E Q UI~MEDX .'( ~ Audible warniug device (siren) with at least 2 diflbrcnt eones. []~] Visual warning devices (lights) with alternating red and/or blue llashing or rotating visible Ii'mn all sides simultaneously aud clear flashing or oscillating visible t?om fi'ont. COMMUNICATIONS EQUIPMENT Mobile VHF radio with appropriate State, Pitkin County and individual agency fi'CtlUcucics. Mobile U[IF radio with appropriate State, Pitkin County, hospital and individual agency fi'Ctluencics. Portable radio with charger and/or cellular phoue tbr back-up communications w/th dispatch and hospitals. MEDICAL EOUIPMENT AND SUPPLIES Airway: ~'~'"' Fixed suction system with wide bore tubing, rigid pharyngeal curved suction tip and soft catheter suction tip with sizes from 5 Fr. to 14 Fr. -4~ Portable suction system with wide bore tubing, rigid pharyngeal carved suction tip and soil catheter suction tip with sizes from 5 Fr. to 14 Fr. ~ Bulb Syringe. _~. Nasopharyngeal airways in pediatric and adult sizes. q OropharyngeaI airways in pediatric and adult sizes. AU Bite stick or equivalent (oropharyngeal airway). -~'~ Fixed oxygen system with a minimum storage capacity of 125 cubic feet (M cylinder) and a minimtan delivery capability for three patients simultaneously at flows of at least i-15 LPM. .k~ Portable oxygen system with a minimum storage capacity of 15 cubic feet (D cylinder) and a nfinimum delivery capability l~br one patient at flows of at least 1-15 LPM. ~ Infant Bag-Valve-Mask with 500cc bag, reservoir and newborn, infant and child masks. _..3~ Adult Bag-Valve-Mask with 1000cc bag, reservoir and adult mask. 'Oxygen masks ** All mask attaclunents must be 15mm** 4// and cannulas capable of delivering oxygen to adults and inlhnts at flows of at least l-15 LPM. // Nov OS 02 06:20p Grecorw R. Balko, M.D. [9701 927-4205 p.3 PITK COU ADVANCED LIFE SUPPORT PROVIDER REQUIRED EQUIPMENT CERTIFICATION ~1~_ EOUIPMEMT I. All cquipmcn! iu~d supplies lisled on Ibc Basic Litb Support Required Equipmcut I,isl. 2. Pediatric diagnostic cquipmenl, agc/weight/vital aign~ ch~ ~d &ug dosagc/equipmcnl size list. 3. Adull, pediatric m~d t~co-nalal v~cul~ access supplics ~d equipment as aulhm'izcd m medical protocols approved Ibr Ibis ambulance sc~ice. I Adult, pediatric and neo-.natal entJottacheul lnlubaliml equipment a~ authorized in medical pltdtx:~ds approved lbr Ibis ambnllmce ~e~tee. ~ C~diac monitoffdclibrillator *'ill~ printer alia adult ~ld pc,liatdc monilming, delibrillam~g a~d pacing capabililies as aullmfized m ~nedical pu~locols approved for Ihi~ ambulance service {~. Ph~macological agenls ~d admiaist,'almn equipmenl aud supplies as aulho~izcd in medical pi~dOCOl~ approved lbr this ambul~ce se~wice. 7. Any addimmal equipment and :mpplics n~d~ Io ~rtb~ oiher procedt~es as amhorized ia medical protocols app~uvcd for Ibis mnhulance ~ervicc. c~es ~he equipment and supplies list~ above ~d meets ~e miuimum mqui~cmenls, established by the Stale of Colorado amt Pilkin County, m provide medical ~e and ~spoflation of Ihe sick m~d injur~ at Adv~ced Life Support level. Provision of Adv~eed Life Support is limiled ms described m 3. cci{ 713-6, s~lion 4 "Medical Ads Allowed EMTs and Paramedics" PiffS~l~ ADVI~R'S SIGNAl URE COLO~ M~DICAL LICENS[ NUMBER DATE /A PITKIN COUNTY' VEItlCLE SAFETY AND OPERABILITY CERTIFICATION Ambulance Service Name:..),'ie;4, ,"~,5."~ .:;: ,":,i ,ri I) License Plate: ~., J,i/Ambulance Number: .~, ,. SYSTEMS ACCEPTABLE NOT ACCEPTABLE COMMENTS Wheels & Tires Steering Alignment Suspension Parking Brake ~ Driving Lights Visual Warning Systems Audible Warning Systems Electrical System ~ Exhaust System Fuel System Glass, Mirrors Body & Sheet Metal I, /'?(-~z~....',. ,-'? c"f~-'/"'5; '~/'~ 5;', prolbssing to be a motor vehicle mcchalfiC with training in all o[' the systems listed above, have eval~uated the condition oQhese systems on the ambulance indicated above and have determined this ambulance to be in safe operating condition. This evaluation does not warrantee the future safety and/or operability of this ambulance due to conditions beyond my control. MECHANIC'S NAME " ' AGENCY/COMPANY P!IONE NtJMBER - DAYE COHNTY Cr)PY RFG!STR/~ '!'ION/OWNEBSH!P-TAX RECEJP_L____. 12/L3/19!~3 0.OH 52,U20 08/08/2002 57 U 01SV ~M~--~ ........ ~CO~ o.T ' ................ OWn tax 0.00 EX EX EX 0.00 0. 0.00 0.00 0.00 0.00 0.00 SNO~SS-WILDCAT FiRE ~'~ '~ ~- --~ PIOSO720011B/082005 PROTECTION DIST PO BO]{ 6436 SNOWM3%S S VLG CO 81615 PAID PITKIN 00 08/08/2002 08443]SAM R01 YA 0.00 MOl 6~'~EliICL~E'iI~UflANCE IS COMP~ILSORY IN COL~)RAI'O. N~JN (~°MpI~IANCE IS A MiSD~EANOI'I ["A~FIC O~FENSE INSURANCE IDENTIFICATION CARD ($1A[E} CO 0983 McNeil & Company SSC100365E 0312312002 0312312003 1993 ChevlAmbulance 1GBJK34N6PE185047 T. Charles Wilson Insurance Services 2260 So. Xanadu Way # 280 (303)368-5757 Aurora, CO 80014 Snowmass-Wildcat Fire Protection District 5275 Owl Creek Road Snowmass Village, CO 8t615 SEE IMPORTANT NOTICE ON REVERSE SIDE PITKIN COUNT / APPLICATION FOR AMBULANCE VEIIICLE PERMIT SERVICE INFORMATION Ambulance Service Name: Office Address: ' ~'-'/ 17~ . r:~$ c( ..96, . .>,~:~c~Ta~ }, ('0'2:~' (/ff,,~ ~ t5 s'r~EET/PO nOX / CqTY . STaT~ . ~ .... VOICE FAX . INTERNET VgltlCLg l)esignation: /"/,?c?/)e ' / _ : License Plate: //¢~'d" ~'~'~ VIN. /,~ ~ I ~/ x'~// ,': L //'~ ""' ..hass~s Year:_=fj~)/.~ lusurance Company ~, ~51,~ .,", ........ , Vehicle Location:: 5 "'-" ' ' ' ' ' ' /t;t (~? " S I'REET/PO BOX CITY STA'I E ZIP C'Ol)l~ ....... I~QUEST FOR WAIVER (include reason For request) SERVICE DIRECTOR'S SIGNATURE "Z/' ~ / ~ ___ DA rE (FOR AMBULANCE INSPECTOR'S USE ONLY) Clear CCIC:. Cle~ NCIC:~ Insurance Card Present: ~ Registration Card Present~-~ J~ Permit Fee Attached ~' Basic Life Suppo~ Required Equipment List Attached ~ Mech~ical Condition Certification Attached ,.-~' Advice Litb Support Provider Required Equipment Ceflification Attached Comments~eco~endation: 1 ~ -~ 5 INSI~CTOR'S SIGNATURE ' POSITION DAF~ -- -- PITKLftr COUNTY' BASIC LIFE SUPPORT REQUIRED EQUIPMENT LIST SAFETY EOUiPMENT ... ~ One 2-1/2 lb. or larger ABC fire extineuisher, accessible from the patient compartment and having been serviced within the last year per NFP~A 1 0 Section 4.' ~- One 5 lb. or larger ABC fire extinguisher, accessible from outside the vehicle and having been serviced within the last year per NFPA 10 Section 4.. $-~' Two "NO SIMOKING-OXYGEN IN USE" signs, one in cab and one in patient compartment. &~- Flashlight, 2-D cell equivalent or better with spare bulb and batteries or charger. ~ Set of 3 reflective warning devices. 2( One reflective vest, coat or equivalent for each member of the crew normally assigned. _~At least one "SHARPS" container, clearly labeied and easily accessible in the patient compartment. . Restraining devices for all items not in a securable cabinet EMERGENCY WARNING EOLIIPMENT ~ Audible warning device (siren) with at least 2 different tones. ~ Visual warning devices (lights) with alternating red and/or blue flashing or rotating visible from 'all sides simultaneously and cIear flashing or oscillating visible from front. CO3,'IMUNICATIONS EOUIPMENT ---)__-k-' Mobile VI-IF radio with appropriate State, Pit. kin County and individual agency frequencies. ~ <v Mobile UHF radio with appropriate State, Pitkin County, hospital and individual agency frequencies. 4~ Portable radio with charger and/or cellular phone for back-up communications with dispatch and hospitals. ;IEDICAL EOUIPMENT AND SUPPLIES Airway: Oc Fixed suction system with wide bore tubing, r/gid pharyngeal curved suction tip and soft catheter suction tip with sizes from 5 Fr. to 14 Fr. ._-'~ Portable suction system with wide bore tubing, rigid pharyngeal curved suction tip and soft catheter suction tip with sizes from 5 Fr. to 14 Fr. ~ Bulb Syringe. ..'4-_ Nasopharyngeal airways in pediatric and adult sizes. ._~ Oropharyngeal airways in pediatric and adult sizes. .... Bite stick or equivalent (oropharyngeal airway). ~ Fixed oxygen system with a minimum storage capacity of 125 cubic feet (M cylinder) and a minimum delivery capability for three patients simultaneously at flows of at least 1-15 LPM. ...... "~C- Portable oxygen system with a minimum storage capacity of 15 cubic feet (D cylinder) and a minimum delivery capability for one patient at flows of at least 1-15 LPM. a~ Infant Bag-Valve-Mask with 500cc bag, reservoir and newborn, infant and child masks. ~ Adult Bag.-Valve-Mask with 1000cc bag, reservoir and adult mask. ~ ,~Oxy~enmasksandc . **All mask attaclaments must be 15mm** annulas capable of delivering oxygen to adults and infants flows of at least 1-15 LPM. at PITKIN CO UNT BASIC LIFE SUPPORT REQUIRED EQUIPMENT LIST MEDICAL EOUIPNIENT AND SUPPLIES Diagnostic: ._ Blood pressure cuffs in large adult, regular adult, child, infant and neonatal sizes. Stethoscopes in adult and pediatric sizes. <~C Pulse oximeter with adult and pediatric sensors. Immobilization & Splinting: ~ One lower extremity traction splint. ~x~ Upper and lower extremity splints of any type (vacuum, air, SAM, wire, board, etc.). -¥ Long spineboard, vacuum mattress or equivalent with appropriate accessories to immobilize patients from head to heels. ~' One orthopedic stretcher (scoop). .~- Short spineboard, KED or equivalent with appropriate straps to immobilize patients from head to pelvis. ...~-' Pediatric spineboard or adult spineboard adaptable to pediatric use. -~'~ Adult and pediatric sized head immobilization equipment for each long spineboard and/or scoop stretcher carried. '~" Rigid cervical inamobilization collars in tall adult through infant sizes. Wound Care: .:--~- Bandages, including but not limited to, roller gauze, triangular and elastic per agency needs. 't. cS'" Dressings, including but not limited to, trauma, ABD, gauze, occlusive and bandaids per agency needs. / ~ Sterile burn sheets. -A--'- Povidone and alcohol swabs or equivalent. -k'-~ Adhesive tape, including but not limited to, I" and 2" per agency needs. ~ Sterile irrigation solution. ~ ostetrical Supplies: --~ Sterile OB kit to include: towels, 4x4s, umbilical tape or cord clamps, scissors, bulb syringe, sterile blanket and sterile gloves. ~ Silver Swaddler and stocking cap or equivalents. Infection Control: ~ Exam gloves in small, medium and large sizes. , ¥'- Face and eye shields. 4-- Fluid-proof gowns with full length sleeves or equivalent. "x'~ Disinfectant spray or wipes for personnel and equipment. Miscellaneous: ~ Oral glucose. "~ Activated charcoal. ,X~ Heavy duty bandage scissors or shears capable of cutting clothing, belts, boots, etc. .~ Spill-proofemesis container with at least 1 liter capacity. ~ universal or separate male and female urinals. _Multi-level. wheeled gurney Stair chair or equivalent. ~ Blankets. --'c'-- Patient compartment heater. 2 ~ov 05 O~ 06:20p Gre~or~ ~. Balko, ~.O. ~970) 927-4205 p,,2 Nou [!% 02 09:00a Sno~ma~s Fire District 9709838~24 p.2 PITKI3/ ¢OU]VT ADV'AINCED LIFE SUPPORT PROVIDER REQUIRED EQUIPMENT CEi~TIFICATION REOUIRED ALS EQUIi~X~.~EN'i~ I. All equipment and ~'upplies listed on fl~e Basic Lit~ Suppofl R~uired Eqmpmeal ~. Pediatric diagnostic equipmenl, age/weigh~vital signs eharl and drug dosagc/cquipmenl size list. 3. Adull, pcdiaoic ~d neo-n~l vascul~ acce~ supplies ~d equipment ~ amho6zed i. medical prmocolx approved for this mnbulnnce service. ,l. Aduh, pedi~m'ic aud neo nalal endo~ncheal mlubation equipment as aulhu~ed appnrved lot this ambulance ';emice i C~rdiac mmmoffdelibgdlalo~ with primer and adult and ~diatric momlom~g, defib~'illalmg and paciug cap~bililies as authorized in medical prolocols approvefl tier fifi~ :u.bulm~ce ~e~ice approved tbr this ambulam:e 7. ~ly addilional equipment ~d supplies needetl lo ~10m~ mher pr0ced~es as Ulllllt~l-i~tJ ill medical prot~ols approved tbr d'~ ~bu[m~ce service. As Physician Advisor for'~'~Z,&W ~- ' " ~ : ...... ":.:~b , I cerlify t~a{ this ambuiaucc carries Ihe equipment and supplies listed above and meets the nfinimum requirements, eslablished by the Slale of Colorado mid Pilkin County, to provide medical cme and transporl,qion of the sick and inj reed at fl~e Advanced Life Supporl. level. Provision of Advanced Life Support is limited as described in 3-CCR-713-6. Seclion 4 "Medical Acts Allowed EMTs and Paramedics." f~IYSlCIAN ADVISOR'S SIGNATURE CI)LORADO MEDICAL LICENSE NUMBER I)A [ E PITKIN ¢OUNT VEItlCLE SAFETY AND OPEl*ABILITY CERTIFICATION : . ~ 7., t, &'r>rX" Plate: i/,~I:._7'3~ Ambulance Number: Ambulance Service Name:_. Jl~. l~', )5/ 4 5 t ~ ,~, ~, ,.., ~ /'? l) L,cense ' SYSTEMS ACCEl'TABLE NOT ACCEPTABLE COMMENTS 'Wheels & Tires Steering Alignment -./ Suspensi°u Service Brakes .... - ..... Parking Brake .Driving Lights Visual Warning Systems Audible Warning Systems , Electrical System Exhaust System Fuel System ' Glass, Mirrors Body & Sheet Metal 'q I, (~~-~e , prolkssing to be a motor vehicle mecha,fic ~vith training in all of the systems listed above, evaluated the condition of these systems on the mnbulance indicated above and have determined this ambulmice to be in safe operating condition. This evaluation does not warrautee the future safety and/or operability of this ambulance duc to conditions beyond my control. ~IECHANIC'S NAME ,4 ~GENC~,'(~OMPANy ' ,~ PIIONE NUMLIER DAFE COUNTY COPY REGISTRATION/OWNERSHIP-TAX RECEIPT TYPE PLATE TAB/MAE VIN EXPIRE PAS- REG VCW787 F079779 1GBJK34J1WF010615 07/2003 TITLE YR MAKE SODY CWT/PAS TlC FLEET~ PREV EXP 57E177638 1998 CHE AM 96 C 07/2002 PUR. DATE PUR. PR~UE ORIG~AL TAXABLE VALUE BUS. DATE CD # UR/CODE 03/14/1998 77160.00 65,586 07/16/2002 57 U 01SV OWNER NAME/MAiLING ADDRESS SNOWMASS WILDCAT FIRE P/0'7022002/6/072004 PROTECTION DISTRICT PO BOX 6436 SNOWMASS VLG CO 816/5 PAID P£'FKIN [0 07/16/2002 0726LENRC R0[ YA 0.00 ~sr^rEi CO INSURANCE IDENTIFICATION CARD 0983 McNeil & Company SSC100365E 0312312002 0312312003 , T. ~.rles~on~nsurance Se~lces 2260 So. Xanadu Way ~ 280 (303)368~757 Aurora, CO 86614 INSURED Snowmass-WIIdcat Fire Protection District 5275 Owl Creek Road Snowmass ~llage, CO 81615 SEE IMPORTANT NOTICE ON REVERSE SIDE