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HomeMy WebLinkAboutbocc.con.151.2003LICENSE AGREEMENT NO./5¥-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 o£County Commissioners o~'Pitkin County, Colorado, does hereby grant a license to the above-named applicant to provide ambulance service within Pitkin County. This Iicense shall have upon it any restrictions listed below, shall be granted any waivers listed below, and shall be valid for the dates listed below, unless revoked by the Board pursuant to the provisions of Pitkin County Resolution No. 87-7 and any other applicable 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, C.R.S. RESTRICTIONS/CONDITIONS: N/A WAIVERS GRANTED: N/A THIS LICENSE IS VALID FROM: january 1, 2004 through December 31, of 2004. APPROVED BY THE PITKIN COUNTY BOARD OF COUNTY COMMISSIONERS ON October 22, 2003. ;/Jack Hatfield, ~g~hairman ~'// Pitkin County Board of County Commissioners PITKIN COUAITY' APPLICATION FOR AMBULANCE SERVICE LICENSE Doing Business As: ~[xq ~L ~ &~C>x/~. Office Address:b-'~_~ ('3~i ~k~d/~x Gq3~ ST~ BOX Office Communications: q~5 VOICE SERVICE INFORMATION Service Type: PUBLIC ~ PRIVATE BLS Number of Ambulances Licensed: FAX ALS ~ STATE ZIP CODE --E-MAIL INTERNET Service Director: ~\[~ a~h ~-. ~O~q~ PHYSICIAN ADVISOR INFORMATION ST~i/~ BOX ..... ice Co~cations: ~M~- ~ VOICE FAX Colorado License Number: ~'-] STATE ZIP CODE E-MAIL IN'TERNET 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 prosecution. SERVICE DIRECTOR'S SIGNATURE DATE PHYSICIAN ADVISOR'S SIGNATURE DATE Date Received: EMS Council Comments: EMS Council Recommendation: EMS Council Chairperson Signature: ) Date Referred to BoCC: (FOR EMS COUNCIL USE ONLY) Ambulance Permits Attached: 3 NAME ~- DATE BoCC Action: Date: PITKIN CO UArI APPLICATION FOR AMBULANCE VEHICLE PERNIIT SERVICE INFORMATION Ambulance Service Name: ~cx~,~-[,5'~.\rkc.c0r ~25~9_'~..agrE_<~ o~r ~ ~ S~e ~/~ BOX C~ ~SYA~ Office Co~cations: qX~ --'~[~ q~ :-~M Ys~o~O ~%~ ,N ~ VOICE FAX ~ E-g~L ~HICLE INFO~ATIO~ S~ BOX C~ x STA~ ~OU~ST FOR WAI~R (includ~ r~on for r~que~) ZIP CODE 4x4: yes ~5( no Exp~rauon. % ~ ZIP CODE SERVICE DIKECTOR'S SIGNATURE Clear CCIC: Clear NCIC: ~'/ Permit Fee Attached ~roa A~CE INSPECTOR'S USE ONLY) Insurance Card Present: ~ Registration Card Present: ~'- Basic Life Support Required Equipment List Attached ~" Mechanical Condition Certification Attached ~ Advance Life Support Provider Requi.r. ed Equipment Certification Attached Comments/Recommendation: ItqSPECTOR'S SIGNATURE POSITION DATE 5 PITKIIV CO ADVANCED LIFE SUPPORT PROVIDER REQUIRED EQUIPMENT CERTIFICATION I. All equipment and supplies listed on the Basic Life Support Required Equipment List. 2. Pediatric diagnosti6 equipment, age/weight/vital signs chart and drug dosage/equipment size list. 4dult, pediatric and nco-natal vascular access supplies and equipment as authorized .in medical protocols approved for this ambulance service. · Adult, pe&atnc and nco-natal endotracheal intubation equipment as authorized in medical protocols approved for this ambulance service. 5. Cardiac monitor/defibrillator with printer and adult and pediatric monitoring and defibrillating capabilities as authorized in medical protocols approved for this ambulance service. ';. Pharmacological agents and administration equipment and supplies as authorized in medical protocols approved for this ambulance service. 7. Any additional equipment and supplies needed to perform other procedures as authorized in medical protocols approved for this ambulance service. As Physician Advisor for ~,~,,~-(~.~'~ \~c &~r ~ ~"-~c33~.-~) '~ , I certify that this ambulance carries the equipment and supplies listed above and meets the'minimum requirements, established by the State of Colorado and Pitkin County, to provide medical care and transportation of the sick and injured at the Advanced Life Support level. Provision of Advanced Life Support is limited as described in 3-CCR-713-6, Section 4 "Medical Acts Allowed EMTs and Paramedics." PHYSICIAN ADVISOR'S SIGNATURE COLORADO MEDICAL LICENSE NUMBER DATE PITKIN COUNTY' VEHICLE SAFETY AND OPERABILITY CERTIFICATION SYSTEMS ACCE~PT~ABLE I NOT ACCEPTABLE COMMENTS Wheels & Tires Alignment Suspension ,~' ,' Service Brakes Parking Brake Driving Lights Visual Warning Systems Audible Warning Systems _~lectrical System ,~Exhaust System ~~ '~' 'Fuel System ~_/4F_ ' , Glass, Mirrors Body & Sheet Metal l,t~'~ ~ r_/ ~ ~/~= r~' , professing to be a motor vehicle mechanic with training in all of the systems listed above, have evaluated the condition of these systems on the ambulance indicated above and have determined this ambulance to be in safe operating condition. This evaluation does not warrantee the future safety and'or operability of this ambulance due to conditions beyond my control. MECHANIC'S NAME DATE AGENCY/COMPANY PHONE NUMBER P1TKI V COI]IVTY BASIC LIFE 'SUPPORT REQUIRED EQUIPMENT LIST SAFETY EOUIPMENT ~.d One 2-1/2 lb. or larger ABC fire extinguisher, accessible from the patient'compartmem and ha~,ing been ~ serviced within the last year per NFPA 10 Section 4[~ ~'O(6~ne 5 lb'withinthela_~t vear~,-, N;:~a ~ n c~,,.._ A°r larger ABC fire extinguisher, accessible from outside the vehicle and having been serviced .N~ Tw° '~o,sM~6~-i~6_'~'6~l~'~l-~[j~'~,,";igns' one incab and one in patient compartment: B~a-d Flashlight, 2-D cell equivalent or better with spare bulb and batteries or charger ~ Set of 3 reflective warning devices. ~ ,¢ One reflective vest, coat or equivalent for each member of the crew normally assigned. DaO At least one "SHARPS" container, clearly labeled and 'easily accessible in the patient compartment. gao Restraining devices for all items not in a securable cabinet EMERGENCY WARNING EOUIPMENT Xt~<,) Audible warning device (siren) with at least 2' differem tones. 0,'DO Visual warning devices (lights) with alternating r~d and/or blue flashing or rotating visible fi'om all sides simultaneously and clear flashing or oscillating visible from front. COMMUNICATIONS EOUIPMENT -"~ {~¢~/Mobile VI-IF radio with appropriate State~, Pitkin C0unly and individual a enc fre uencms _~ ..... g Y q ' . Paa~ Mobile UHF radio vath a . ·" , ...... · . , .. ppropnate State, P~tkin Cottn , hos gal and md~wdual ' i'086-aPortable radio with char~,er s,,,~/ .... ,_~__ k,_ '.. , '~' ~,,.~;> · p . '. .~ge.n. qy frequencies. . . . e ,-,~,~, ,.~nm,u phone Ior t~acK-up commumcatlons w~th dlspatch and nosp~tats. /IEDICAL EOUIPMENT AND SUPPLIEg Airway: ~44.0 Fixed suction system with wide bore tubing, rigid phmyngeal curved suction tip and soft catheter suction ,o~.~ tip with sizes from 5 Fr. to 14 Fr. ~o~x,~\ 3 4'?ortable suction Syjlem~h~,4de.~b~bing, rigid pharyngeal curved suction tip and soft catheter '~'~ suction tip.with sizes from 5 Fr. to 14 h4x~ Bulb Syringe. ~-- ~,~,~,.r~-~-, . . '~'. . 4'" tOo~.--7__~asopharyngeal a, rways m~e-d~d adult sizes. ~_.~r~ Oropharyngeal airways in p~d adult sizes. ,.-~q4~/Bite stick or equivalent (oropharyngeal airway). ~tan,,J Fixed oxygen system with a minimum storage capacity of 125 cubic feet (M cylinder) and a minimum delivery capability for three patients simultaneously at flows of at least 1-15 LPM. Portable oxygen system with a m~nimum storage capacity of 15 cubic feet (D cylinder) and a minimum delivery capability for one patient at flows of at least 1-15 LPM. · Infant Bag-Valve-Mask with 500cc bag, reservoir and newborn, infant and child masks. Adult BagrValve-Mask with 1000cc bag, reservmr and adult mask. **Ail mask attachments must be 15mm** Oxygen masks and cannulas capable of delivering oxygen to adults and infants at flows of at least 1-15 LPM. PITKItV COUAtTY' BASIC LIFE SUPPORT REQUIRED EQUIPMENT LIST MEDICAL EOUIPMENT AND SUPPLIE,q Diagnostic: ~ Blood pressure cuffs in large adult, regular adult, childs:infant and neonatal sizes. ~uJ Stethoscopes in adult and pediatric sizes. b4d Pulse oximeter with adult and pediatric sensors. Irr~obilization & Splinting: ~..$~ One lower extremity traction splint. ~ Upper and lower extremity splints of any type (vacuum, air, SAM, wire, board, etc.). f~ll~t.J Long spineboard, vacuum mattress or equivalent with appropriate accessories to inunobilize patients from head to heels. _ One orthopedic stretcher (scoop). Short spineboard. K.ED or equivalent with appropriate straps to immobilize patients froln head to pelvis. .f,~v~J 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. i~,a~D Rigid cervical immobilization collars in tall adult through infant sizes. Wound Care: ~,dBandages, including but not limited to, roller gauze, triangular and elastic per agency needs. "~ Dressings, including but not limited to, trauma. ABD, gauze, occlusive and bandaids per agency needs. -~ Sterile burn sheets. ..~ Povidone and alcohol swabs or equivalent. · ~t~o Adhesive tape, including but not limited to, 1"' and 2" per agency needs. ~%4~J Sterile irrigation solution. ~vstetrical Supplies: .~y,) Sterile OB kit to include: towels, 4x4s, umbilical tape or cord clamps, scissors, bulb syringe, sterile ~j 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. Bq~,JFluid-proof gowns with full length sleeves or equivalent. ~ Disinfectant spray or wipes for personnel and equipment. Miscellaneous: ~ Oral glucose. ~ Activated charcoal. .~ Heavy duty bandage scissors or shears capable of cutting clothing, belts, boots, etc. ~ Spill-proof emesis container with at least 1 liter capacity. I~.J umversal or separate male and female urinals. o.~lO Multi-level. wheeled gumey '~q:~ Stair chair or equivalent. J..~__) Blankets. t.~c/Patient compartment heater. 2 COLORADO~REGISTRATION/OWNERSHiP TAX RECEIPT TYPE r ~ ATE TABNAL VIN EXPIRE PAS-REG VCW807 M662840 1GBJK34N6PE185047 08/2004 57E147144 1993 CHE A)4 92 C 08/2003 12/13/1993 0.00 52,020 08/20/2003 57 U 01SV 0.00 EX EX EX 0.00 0.00 0.00 . 0.00 0.00 0.00 0.00 G HI SVW HC D^TE SNOWMASS - W J:LDCAT FIRE PROTECTION DIST P/OSO82003/B/082005 PO BOX 6436 ~ SNOW)4ASS VLG CO 81615 PAID PITKIN 00 08/20/2003 125310SAM R0i YA 0.00 COLORADO AUTO INSURANCE IDENTIFICATION CARD NAMEOF INSURANCE American Alternative Insurance Corporation COMPANY fo! ~)odily injury, properly damage and personal injury protection ('no4auE" insurance) in at least the [' Name of Insured SNOWMASS-WlLDCAT FIRE PROTECTION DISTRICT . PO BOX 6436 8NOWMASS VILLAGE CO 81615 L Applicable with respect to the following Motor Ve CHEVY POLICY NUMBER VFIS CL -0022123-0 EFFECTIVE DATE O3/23/03 EXPIRATION DATE 03/ 23! 04 licle: 1993 /, AMB ALS 1GBJ~K34N6PE185047 This Card should be carried in the vehicle at all tinms as evidence of insurance. PTI'KIN COUIvT'Y' , APPLICATION' FOR AMBULANCE VEHICLE PERMIT SERVm~ ~NFO~ATION S~ BOX C~ ~ z STA~ ZIP CODE om~ Co~cat~on~: q~%-~ ~ ~q 5~¢.~,N&~ VOICE FAX EJM~L ~ gHICLE INFORMATION Desi~afion: ~0~ ~ License Plate: q~ ~ ~:~['~$~D~ ~' Ch~sis Ye~: F~ T~: ~ ¢ ~ m 4~4: y~ ~ ~o M~e: I~ce Comp~y:~mc&~ ~MM~7. PolicyN~ber:VF~S CL~i~ Expiration:~-~-0~q Ve~cle Location: S~ BOX C~ STA~ ' ZIP CODE .~OUEST FOR WAI~R (include re.on for request) SERVICE DIRECTOR'S SIGNATURE DATE (FOR AMBULANCE INSPECTOR'S USE ONL30 Clear CCIC: Clear NCIC: Insurance Card Presem: ~ Registration Card Presem:~ ~ Permit Fee Attached ~'~ Basic Life Support Required Equipment List Attached "~ Mechanical Condition Certification Attached ~Advance Life Support Provider Requi.rpd Equipment Certification Attached Corranents/Recommendation: POSITION DATE PITKIN COUIIT] ADVANCED LIFE SUPPORT PROVIDER REQUIRED EQUIPMENT CERTIFICATION Ambulance Service Name: St4.xu~-v.~'~\~ca3r ~"¢.C'-~. ~['~'~¢.Ambulance Designation: REOUIRED ALS EOUIPMENT 1. All equipment and supplies listed on the Basic Life Support Required Equipment List. 2. Pediatric diagnostic equipment, age/weight/vital signs cmn and drug dosage/equipment size list. ~ ~,dult, pediatric and nco-natal vascular access supplies and equipment as authorized in medical protocols approved for this ambulance service. 4. Adult, pediatric and nco-natal endotracheal intubation equipment as authorized in medical protocols approved for this ambulance service. 5. Cardiac monitor/defibrillator with printer and adult and pedialric monitoring and defibrillating capabilities as authorized in medical protocols approved for this ambulance'service. Pharmacological agents and administration equipment lind supplies as authorized in medical protocols approved for this ambulance service. 7. Any additional equipment and supplies needed to perform other procedures as authorized in medical protocols approved for this ambulance service. As Physician Advis°r f°r ~kla~ axa<~g- (,x~\ ~f~q3r ~- '~f~ ,"~ ~¥, , I certify that this ambulance carries the equipment and supplies listed above and meets the'minimum requirements, established by the State of Colorado and Pitkin County, to provide medical care and transportation oft.he sick and injured at the Advanced Life Support level. Provision of Advanced Life Support is limited as described in 3-CCR-713-6, S ctmn 4 Medmal Ac~s Allowed EMTs and Paramedics." PHYSICIAN ADVISOR'S SIGNATURE COLORADO MEDICAL LICENSE NUMBER DATE PffKt COt/mY VEHICLE SAFETY AND OPERABILITY ,, CERTIFICATION SYSTEMS ACCEPTABLE NOT ACCEPTABLE COMMENTS Wheels & Tires ~/[~-'- , eering Alignment Suspension Parking Brakea5~5~.~< .,,. : Driving Lights - , Visual Warning Systems 'eff'~C~, ' Audible Warning Systems , .. _,ElectricalSystem ., ..,; . ,. t System , " , Fuel System ' ' ' Gl~ss, Mirrors Body & Sheet Metal I,., , ~:., .( /~--/-', ~' ~' ~' , professing to be a motor vehicle mechanic with training in all of the systems listed above, have'evaluated the condition of these systems on the ambulance indicated above and have determined this ambulance to be in safe operating condition. This evaluation does not warrantee the furore safety and/or operability of this ambulance due to conditions beyond my control. MECHANIC'S NAME ) AGENCY/COMPANY PHONENUMBER DATE // PITKI_4r COU. q BASIC LIFE SUPPORT REQUIRED EQUIPMENT LIST SAFETY EOUIPMENT ,~_~_~q'One 2-I/2 lb. or larger ABC fire extinguisher, accessible from the patient compartment and having been la~ serviced within the last year per NFPA 10 Sect~ ~.) on 4. )~'~ .~"One 5 lb.'or larger ABC fire extinguisher, accessible from 6utside the veh' ' . . ' w~.~.:_ .~._, .......... . role and having been serviced 'thin me ias[ year per ~r~A lO 5ectmn 4.. R~Two "NO SMOKING-OXYGEN IN USE" signs, one in cab and one in patient compartment. ~4/I~) Flashlight, Z-D cell equivalent or better with. spare bulb and batteries or charger. ___ Set of 3 reflective warning devices. One reflective vest, coat or equivalent for each member &the crew normall .assi ned , ,, ,, . Y g . '.lu~ At least one SHARPS container, clearly labeled and easil7 accessible in the patient compartment. F-4td Restraining devices for all items no~ in a securable cabinet EMERGENCY WARNING EOUIPMENT ,~hq] Audible warmng device (siren) with at least 2 different tones. f4~.2 Visual warning devices (lights) with alternating red and/or blue flashing or rotating visible from all sides simultaneously and clear flashing or oscillating visible from front. COMMUNICATIONS EOUIPMENT -~_J_~ Mobile VI-IF radio with appropriate State, Pitldn Comu7 and individual agency frequencies. if--~'~Mobile UI-IF radio with appropriate state, Pitkin County, hospital and individual agency frequencies. hit~,J Portable radio with charger and/or cellular phone for back£up communications with dispatch and hospitals. /IEDICAL 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. ~ 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. ~r~ ~ Bulb Syringe. " ' " ~, I~q[ )[4X~J Bite stick or equivalent (oropharyngeal airway) } ~) Fixed oxygen system with a minimum storage capacity of 125 cubm feet (M cylinder) and a minimum ,delivery capability for three patients simultaneously at flows of at least 1-15 LPM. ~t~JPortable 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. I[~A~ Infant Bag-Valve-Mask with 500cc bag, reservoir and newborn, infant and child masks. P, tt~ Adult BagrValve-Mask with 1000cc bag, reservoir and adult mask. ) a~ **All mask attachments must be 15mm** ~Oxygen m ks and cannulas capable of delivering oxygen to adults and infants at flows of at least 1-15 LPM. fy- BASIC LIFE SUPPORT REQUIRED EQUIPMENT LIST MEDICAL EOUIPMENT AND SUPPLIES Diagnostic: '~ Blood pressure cuffs in large adult, regular adult, child; infant and neonatal sizes. ~uJ Stethoscopes in adult and pediatric sizes. ~2~-,,J Pulse oximeter with adult and pediatric sensors. Immobilization &,Splinting: __~ One lower extremity traction splint. ~ Upper and lower extremity splints of any type (vacuum, air, SAM, wire, board, etc.)~. ~ Long spineboard, vacuum mattress or equivalent with"appr0priate accessories to immobilize patients from head to heels. ~ One orthopedic stretcher (scoop). ~d~ Short spineboard, KED or equivalent with appropriate straps to immobilize patients from h,ead to pelvis. ~ Pediatric spineboard or adult spinebo~d adaptable to, pediatric use. ' ' , ~,x~l Adult and pediatric sized head inunobflization equipment for'each long spineboard and/or scoop stretcher carded. .~o,.J Rigid cervical immobilization collars in tall adult through infant sizes. Wound Care: ~,.~[ Bandages, including but not limited to, roller gaud. e, .triangular and elastic per agency needs. '~.~_~ Dressings, including but not limited to, trauma, .ABD,'ga. uze, Occlusive and bandaids per agency needs. "~..~_~. Sterile bum sheets. . . .~ ... -'k ' ~: ~ . NU~ Povidone and alcohol swabs or equivaleni.~ ' ,,. ,,: ,..,. '/.,,.' ,...~' , .. i" _t!.~J Adhesive tape, including but not limited to, l'"hnd2;' i~er'agency needs. /M~-J Sterile irrigation solution. ,ostetrical Supplies: ~ Sterile OB kit to include: towels, 4x4s, umbilical tape or cordclamps, scissors, bulb syringe, sterile blanket and sterile gloves. ~ Silver Swaddler and stocking cap or equivalents. Infection Control: ~'q~J Exam gloves in small, medium and large sizes. ~,~_~. Face and eye shields. ~ Fluid-proof gores with full length sleeves or equivalent. r~o~ Disinfectant spray or wipes for personnel and equipment. Miscellaneous: ~ Oral glucose. ~ Activated charcoal f¢~ Heavy duty bandage scissors or shears capable of cutting clothing, belts, boots, etc. h/~J Spill-proof emesis container with at least 1 liter capacity. universal or separate real e and female urinals. Multi-level. wheeled gurney )~ Stair chair or equivalent. -J_~____ Blankets. ~ Patient compartment heater. 2 COLORADO REGISTRATION/OWNERSHIP TAX RECEIPT TYPE ~LATE TABNAL VIN EXPIRE PAS- REG 471GPI M655524 1FDWF37F32EA13220 04/2004 TITLE YR MAKE BODY CWT/PAS T/C FLEET# PREV EXP 57E195420 2002 FOR AM 110 C 04/2003 PUR, DATE PUR. PRICE ORIGINAL TAXABLE VALUE BUS. DATE CO # UR/CODE 03/27/2002 87050.00 73,992 04/24/2003 57 O 01SV EM. FEE PRIOR O,T. OWN TAX LIC, FEE TITLE FEE OTHER FEE 0.00 EX EX EX 0.00 0.00 RTU TAX COUNTY TAX CITY/DIST TAX 0.0o 0.00 0.00 ~i:i i~-~'~ :::::' ii:iii:: M LES SNOWMAS8 WILDCAT FIRE PROTECTION DIST STATE TAX SPECIAL FEE FUEL 0.00 0.00 D Hi GVW HC DATE SIGNATURE REQUIRED P.O. BOX 6436 ONREVERSE SNOWMASS VLG CO 81615 SIDE, VALIDATION TOTAL PAID PITK1N 00 04/24/2003 150930DSM R01 A 0.00 MOTOR VEHICLE INSURANCE IS COMPULSORY IN COLORADO, NON-COMPLIANCE IS A MISDEMEANOR TRAFFIC OFFENSE COLORADO AUTO INSURANCE IDENTIFICATION CARD NAME OF INSURANCE American Alternative Insurance Corporation COMPANY r Name of Insured SNOWMASS-WlLDCAT FIRE PROTECTION DISTRICT PO BOX 6436 SNOWMASS VILLAGE CO 81615 L ] POLICY NUMBER VFIS CL -0022123-0 EFFECTIVE DATE 03/23/03 J EXPIRATION DATE 03 / 23 / 04 ~icle: Applicable with respect to the following Motor VE FORD 2002 / AMD ALS 1FDWF37F32EA13220 This Card should be can'ied in the vehicle at all times as evidence of insurance. R1321 {~d. 1~2) UP&S APPLICATION FOR AMBULA~N~E VEHICLE PER~IT SERVICE INFORMATION Ambulance Service Name: ~aoua(~f_~- (~\~_c.~ -~_~_~c~Jc~__C-~ ¢,.~ -'~?S3~ (L-~ S~O BOX C~ ~ ~A~ ZIP CODE VOICE FAX E'~L' ~ ~ :meLt Desi~adon: 0~L~, ~ License Plate:vc_~ -~ ~: ~~ (,)~O~O~ ~ Ch~sisYe~: ~ M~e:~%~ T~e:I ~ II III 4x4:yes ~ no I~ce Comp~y:~(~ ~e~t~g~. Policy Nmber~V~/~ Ck~ ~fi~z-6 Expirafion:~-~q~ ~ BOX C~ ~ / STA~ ZIP CODE ~ ~OUEST FOR WAI~R (include re.on for reque~) SERVICE DIRECTOR'S SIGNATUKE (FOR AMBULANCE INSPECTOR'S USE ONLY) Clear CCIC:. Clear NCIC: Insurance Card Present: ~ "'" Permit Fee Attached ~ Basic Life Support Required Equipment List Attached · '"' Mechanical Condition Certification Attached ~ Advance Life Support Provider Requi~ed Equipment Certification Attached Comments/Recommendation: Registration Card Present:-~ INfS PECTOR'$ SIGNATURE POSITION PITKIN CO UiWI'Y' ADVANCED LIFE SUPPORT PROVIDER REQUIRED EQUIPMENT CERTIFICATION Ambulance Service Name:~n6t~a~-(~0~l~C.A~- 2~t.%'~ ~$~ Ambulance Designation:~z~ C~ REOUIRED ALS EOUIPMENT 1. All equipment'and supplies listed on the Basic Life Support Required Equipment List. 2. Pediatric d'iagnostid equipment, age/weight/vital signs chart and drug dosage/equipment size list. 4dult, pediatric and nco-natal vascular access supplies and equipment as authorized ,in medical protocols approved for tlfs ambulance service. 4. Adult, pediatric and nco-natal endotracheal intubation equipment as authorized in medical prot6cols approved for this ambulance service. 5. Cardiac monitor/defibrillator with printer and adult and pediatric monitoring and defibrillating capabilities as authorized in medical protocols approved for this ambulance service. Pharmacological agents and administration equipment and supplies as authorized in medical protocols approved for th/s ambulance service. 7. Any additional equipment and supplies needed to perform other procedures as authorized in medical protocols approved for this ambulance service. As Physician Advisor for ~-~-(X~\&c~ ~ ~"~4 ~ ~-~ I~%~-, , I certify that this ambulance carries the equipment and supplies listed above and meets the'minimum requirements, established by the State of Colorado and Pitkin County, to provide medical care and transportation of the sick and injured at the Advanced Life Support level. Provision of Advanced Life Support is limited as descr/bed in 3-CCR-713-6, Section 4 "Medical Acts Allowed EMTs and Paramedics." PHYSICIAN ADVISOK'S SIGNATURE COLORADO MEDICAL LICENSE NUMBER DATE PITKIIg COU. IVTY' VEHICLE SAFETY AND OPERABILITY CERTIFICATION SYSTEMS ACC.~EPT,~BLE NOT ACCEPTABLE , COMMENTS eering Fr~ :g~f ., Alignment Suspension . · . Service Brakes ~__~ " Parking Brake Driving Lights Visual Warning Systems Audible Warning Systems~ ~ ' : ,. ' .. ' _.Electrical System. ' . '' ...' . .jExhaust System . Fuel System Glass, Mirrors flody & Sheet Metal . I, ~.'~< ~/'-%4~ , professing to be a motor vehicle mechanic with training in all ofthe systems listed above, have ~eyafuated the condition of these systems on the ambulance indicated above and have determined this ambulanc6 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. -- blECHANIC'S NAME / AGENCY/COMPANY PHONE NUMBER DATE ) PITKIIV COUiVTY' BASIC LIFE SUPPORT REQUIRED EQUIPMENT LIST SAFETY EOUIPMENT .Y=aa_,a~One 2-1/2 lb. or larger ABC fire extinguisher, accessible from the patient compartment and ravin been ~.~*~o ~r~- serviced within the last vear her NFP~ ~ n ~.~,;^- ~'~ ' , g ~-~ 5 lb. or larger ABC fire extmgmsher, accessible from' outside the vehicle and hav g been serviced w~thin the last year per NFPA I 0 Section 4.. . g~-f Two '2qO SMOKING-OXYGEN IN USE" signs, one in cab and one in patient compartment. ~.~d Flashlight, 2-D cell equivalent or better with spare bulb and batteries or charger. ~,to Set of 3 reflective warning devices. ~ One reflective vest, coat or equivalent for each member oft_he crew normally,assigned. *¢,~-,~ At least one "SHARPS" container, clearly labeled and easily accessible in the patient compartment. ~ Restraining devices for all items not in a securable cabinet EMERGENCY WARNING EOUIPMENT ~L~Audible warning device (siren) with at least 2 different tones. ~14,,J Visual warning devices (lights) with alternating red and/or blue flashing or rotating visible from all sides simultaneously and clear flashing or oscillating visible from front. COMMUNICATIONS EOUIPMENT ~"~gt~O Mobile VI-IF radio with appropriate State, Pitkin Coumy and individual agency frequencies. -~..¢~a~J Mobile UIIF radio with appropriate State, Pitkin County, hospital and individual agency fi'equencies. ~L~ Portable radio with charger and/or cellular ph6ne for back-up communications with dispatch mad hospitals. /IEDICAL EOUIPMENT AND SUPPLIES Airway: ~ Fixed suction system with wide bore tubing, rigid pharyngeal curved suction tip and soft catheter ~uction tip with sizes from 5 Fr. to 14 Fr. ~ Portable suction system with wide bore robing, rigid pharyngeal curved suction tip and soft catheter suction tip with sizes from 5 Fr. to 14 Fr. lhg, J Bulb Syringe. ~o~.~. & ~"Nasopharyngeal airways m ~d adult sizes. °~'q~ !~-n~ Or°Pharyngeal airways in p'~i-a~-e-and adult sizes. _ ._._~ Bite stick or equivalent (oropharyngeal airway). [~to Fixed oxygen system with a minimum storage capacity of 125 cubic feet (M cylinder) and a minimum delivery capability for three patients simultaneously at flows of at least 1-15 LPM. ... Portable oxygen system with a minimum storage capacity of 15 cubic feet (D cylinder) and a minimum delivery capability for one patient at flows of at least 1-15 LPM. Infant Bag-Valve-Mask with 500cc bag, reservoir and newborn, infant and child masks. Adult Bag:Valve-Mask with 1000cc bag, reservoir and adult mask. O ', . **All mask attachments must be 15rnm** . xygen mas~cs and carmulas capable of delivering oxygen to adults and infants at flows of at least 1-15 LPM. PI]KIN ¢0 UAFI' BASIC LIFE SUPPORT REQUIRED EQUIPMENT LIST MEDICAL EOUIPMENT AND SUPPLIE,q Diagnostic: %14-~ Blood pressure cuffs in large adult, regular adult, child,.dnfant and neonatal sizes. ~ Stethoscopes in adult and pediatric sizes. ~',YaJ Pulse oximeter with adult and pediatric sensors. Immobilization &,Splinting: ~l One lower extremity traction splint. ~ Upper and lower extremity splints of any type (vacuum, air, SAM, wire, board, etc.). ~ Long spineboard, vacuum mattress or equivalent with appropriate accessories to immobilize patients from head to heels. ~ ~ One orthopedic stretcher (scoop). ~ Short spineboard, KED or equivalent with appropriate straps to immobilize patients from head to pelvis. 3flO Pediatric spineboard or adult spineboard adaptable to. pediatric use. ~ Adult and pediatric sized head immobilization equipment for~each long spineboard and/or scoop stretcher carried. ~ Rigid cervical immobilization collars in tall adult through infant sizes. Wound Care: ~ Bandages, including but not limited to, roller gauze, .triangular and elastic per agency needs. ")cOao Dressings, including but not limited to, trauma, ABD, gauze, occlusive and bandaids per agency needs. "~'~0. Sterile burn sheets. ~ . . .. ,, ...' . . __.~fr Povidone and alcohol swabs or equivaleni.' .... , ,,',: ;? .? .', ' P,l~q,-] Adhesive tape, including but not limited to, 1' ian'd .2" per agency needs. ~ Sterile irrigation solution. /ostetrical Supplies: r~q,~ Sterile OB kit to include: towels, 4x4s, umbilical tape or cord clamps, scissors, bulb syringe, sterile blanket and sterile gloves. eci~J Silver Swaddler and stocking cap or equivalents. Infection Control: g,v) Exam gloves in small, medium and large sizes. ~ Face and eye shields. _~ Fluid-proof gowns with full length sleeves or equivalent. Disinfectant spray or wipes for personnel and equipment. Miscellaneous: ~ Oral glucose. ..r3*l,,) Activated charcoal. .~1-~ HcaW duty bandage scissors or shears capable of cutting clothing, belts, boots, etc. ~k~,.~ Spill-proofemesis container with at least I liter capacity. ~ universal or separate male and female urinals. ¢p,-O Multi-level. wheeled gurney bO Stair chair or equivalent. g-~. Blankets. ~--~- Patient compartment heater. 2 07/2004 COLORADO REGISTRATION/OWNERSHIP TAX RECEIPT TYPE ,PLATE TAB~/AL V~N , PAS- REG VCW787 N661886 1GBJK34J1WF010615 TITLE YR MAKE BODY CWT/PAS T/C FLEET# PREV EXP 57E177638 1998 CHE AM 96 C 07/2003 PUR. DATE PUR. PRICE ORIGINAL TAXABLE VALUE BUS, DATE CO # UR/CODE 03/14/1998 77160.00 65,586 08/06/2003 57 U 01SV EM. FEE PRIOR O,T. OWN TAX LIC. FEE TITLE FEE OTHER FEE 0.00 EX EX EX 0.00 0.0( RTD TAX COUNTY TAX CITY/D(ST TAX 0.00 0.00 0.00 UNIT # M LES OWNER NAMB/MAB*ING ADDRESS SNOWMASS WILDCAT FIRE · PROTECTION DISTRICT STATE TAX SPECIAL FEE FUEL 0.00 0.00 G HI GVW HC DATE PO BOX 6436 SNOWNAS~ X~LG CO 81615 P/O7022002/B/O?2004 {irG NATUR E~ EQUIRED[ N REVERSEI PAID PITKIN 00 08/06/2003 130434TE~;I%0i YA 0.00 COLORADO AUTO INSURANCE IDENTIFICATION CARD NAME OF INSURANCE American Alternative Insurance Corporation COMPANY r Name o1 Insured SNOWMASS-WlLDCAT FIRE PROTECTION DISTRICT PO BOX 6436 SNOWMASS VILLAGE CO 81615 POLICY NUMBER VFIS CL - 0022123 - 0 EFFECTIVE DATE 03/23/03 EXPIRATION DATE 03/23/04 ~icle: 1GBJK34JIWF010615 Applicable wi~h respect to the following Motor Ve CHEVY 1998 / AMB ALS This Card should be carried in the vehicle at all times as evidence of insurance.