HomeMy WebLinkAboutbocc.con.003.2006
LICENSE AGREEMENT NO. 003 -2006
PITKIN COUNTY AMBULANCE LICENSE FOR:
ASPEN AMBULANCE DISTRICT
MEDIC 2, MEDIC 3, MEDIC 4, MEDIC 5
GRANT OF LICENSE/PERMIT
The undersigned, representing the Board of County Commissioners of Pitkin County,
Colorado, does hereby grant a license to the above-named applicant to provide ambulance
service within Pitkin County. This license shall have upon it any restrictions listed below,
shall be granted any waivers listed below, and shall be valid for the dates listed below, unless
revoked by the Board pursuant to the provisions of Pitkin County Ordinance # 01-002 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: Not Applicable
WAIVERS GRANTED: Not Applicable
THIS LICENSE IS VALID FROM: January 1, 2006 through December 31, 2006.
APPROVED BY THE PITKIN COUNTY BOARD OF COUNTY COMMISSIONERS
TI(~f.M&tlt "'J ~()tJ~
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Pitkin County Board of County Commissioners
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PITKIN couNTY
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APPLICATION
FOR
AMBULANCE SERVICE LICENSE
GENERAL INFORMA nON
Ambulance Service Name: A.. os p~ --Pwv..;:>,,-J \Aj'o\ C'l<:" ,fA ~\n. \ (> ..
Doing Business As: ( A 'S"t>. .n I ,\, ~\("\ <:> t i> I nc,1\.\ CCHll\1"1 ')
Office Address: 'fc' A. ..",,=-1 \/Acll ...~ o,,:>o,n>o..L () 'to \ (~"'n ..:=..t:A~<...~~ .fb,,~ ('0. e,l \0 It
. . . STREETP.,9BOX (Q, ) CITY. STATE mCODE
. .' ~q,~) " 4 .
.Office Communications: 5'-\ "t - l5i!. <> 'S"lt'-t - \ S,?,
. VOICE FAX E-MAIL INTE~ET
SERVICE INFORMATION
Service Area: f\~o~ [\MP>\liAl.:\r ~ J)\srn.,,,.. .R:.\i~n.",~,~Service Director: i<1f'\.\I\\t" WA.u<{f"
Service Type: PUBLlC-X- PRJVATE_ BLS--X. ALS~ EMERGENT-X. TRANSFER$,. SPECIALEVENTS..A..-
Number of Ambulances Licensed: (" (M ~"'IC L -, -...... - -5' - \ '" - \ , ')
PHYSICIAN ADVISOR INFORM A TIQN
,.:'.1ysicianAdvisorName: ht::! c I~R\S €'vIPo..n.n~......"Z-
Office Address:"g 0 A'>9 E...l \I ~ I ~ \..\;0 "'V \ n>.i '0 't-c \ (r... ",.l.G.. c.\<I....-tt. R:"\' .1\ 'S~
.,.,. STREET(~;:,) (<110) CITY STATE /
ice Communications: ?L.t '-l - \ ~ \.... 5'-\<-t - \ 5"'1 Q
VOICE FAX
Colorado LicenSe Number: ~ 0 ~ '1 3
(0 ~11:'o1l
ZIP CODE
E.MAlL
INTERNET
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 tbat an Ambulance Service License has been issued based .
on false information constitutes grounds for license revocation, suspen' of operations and possible criminal prosecution.
(FOR EMS COVNC
Date Received: \ , t 301 '" ~ Ambulance Permits Attached: <c
i? ~ c;J (,) !'alA ~ J , 0 'At.. I 0 ,.
SERvrCE DlRECTOR'S SIGNATURE to ii
EMS Council Comments: N\ t::D\(' 1.. - ~ - '-\ - '5 N OA.IV\~.. (.:lo. OV ",""..m::::....l.1 .{.IL '{"I''f'''''':l.T U C'AI>J \\:::..
lVl\!::::t>\c \~ - \=1 5A>.<::- \-\~-- S"P'P=r.:t~~3~
EMS Council Recommendation: To ?~ s ~ A \.L Co AMQ,'o,l \AN~ \(j v,!\.} !'ll.tJ 1M \"l '.ll VDn.~ I;) ~.
~MS Council Chairperson Signature: ~ r"2x" fA k,f..'-1U 0-/ '1 ~ r
) /~ ~
Date Referred to BoCC: BoCC Action: Date:
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PITKIN couNTY
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APPLI~A TION
FOR
AMBULANCE VEHICLE PERMIT
SERVICE INFORMATION
~
Ambulance Service Name: ~ ~o ..J -+\M i\ \,) tAN (' I:- n\ '\' fi.\cr
Office Address:~ c ~ ~ (.).U~ \;1"",,,,,, IT'A..L >Clot'" I (~ST\l"'=..Q~t:..=f R:1. l\"re:N.~ 81 \0 It
. S /pO BOX U rC'!' CITY STATE ZIP CODE
(~1"") ,,,,'1"')
. Office Communications: 5'-\ '-t - \ 5' ~ c '5"'Y: L\ - \ 'S , ~ '
VOICE FAX E-MAIL INTERNET
-::HICLE INFORMATION
M cO\(..t.. " (,:;,\..0 _ ~,.... .
De,signation: ~~c.J:>'1 M I U &:"17... License Plate: 0 ~~ - ~ ~c...' VIN: I Fo vJ F ~ 1 ~<<+ 'L.. ~\~ ~4 I z. ~
Chassis Year: 2.00"1- MaJeed;' 110.\\ F- '\ 's -0 Type: I.:i- II _ III _ 4x4: yes X no_
. '
Insurance Company: :-'r i>A...JL(:; W\,,,, ~/\'\A\":\'lOiiPolicyNumber: Gri>o I.. ~ <:> \ Z.~Ln Expiration:, '.1 \ 'Q (..
. . W~~_ ~
Vehicle Location: :-A.I'v'\"'I.I""l>'('~ ~'hl f' r.l1"eJa." 0 Ltc ~ (p,,\.nE. c.n.~(. R:l ~~oe\ Co e.llo 11
. STREETIPO BOX . CITY STATE J , ZIP CODE
..~ ~EOUEST FOR W AIVER(include reason for request)
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..... at>.!"" "Rt=I?\JI~Q
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77 . .c/~ lJA~
SERVICE I!IRECTOR'S SIGNATURE
10'....,...S-
DATE
(FOR AMBULANCE INSPECTOR'S USE ONLY)
Clear CCIC:
Clear NCIC:
Insurance Card Present: t"v
Registration Card Present:jVt,6
iMAl Permit Fee Attached
h.u Basic Life Support Required Equipment List Attached
~ Mechanical Condition Certification Attached
I\.^-\'} Advance Life Support Provider Requi:.ed Equipment Certification Attached
CommentslRecommendation:
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INSPECTOR'S SIGNATURE
tJl~-?
POSITION
lcll-1{or-
ATE
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PITKIN couNTY
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ADVANCED LIFE SUPPORT PROVIDER
REQUIRED EQUIPMENT CERTIFICATION
, ,
Ambulance Service Name: ~ s y ~ AM... '-I1A~\c<sc .thsn'U.C'r'
REOUlRED ALS EOUlPMENT
Ambul~\:e Designation: N\ ~n1r 1.-
1. All equipment and supplies listed on the Basic Life Support Required Equipment List.
,
2. Pediatric diagnostic equipment, age/weight/vital signs chart and drug dosage/equipment size list. '
"l A.dult, pediatric and neo-nat~l vascular access supplies and equipment as authorized in medical protocols
approved for this ambulance service.
4. Adult, pediatric and neo-natal endotracheal intubation equipment 'as authorized in medical protocols
approved for this ambulance service. " ," ,
, ,
,. '"
5. Cardiac monitor/defibrillator with printer and adult and'~~diat:ric monitoring and defibrillating capabilities
as authorized in medical protocols approved for this ~bulance' service. '
, '
, .
". Pharmacological agents and admini~tration equiIlIne~i~d. supplies as authorized in m~dical protocols
, ') approved for this ambulance service. . '; , ,
....;J' , . ., ",.,'" " ' ,. ..
\ " " , ., I "i ',., ,~'. ':: ,,'. I ~.. I;. .'.~ .:, '. ..' " "'. '. '
7. Any additional equipment and supplies needed to 'performoiher proc;edures as authorized in medical
protocols approved for this ambulance service. '
, '
As Physician Advisor for A. s p~ ""'" ~v It:\ No ~ p\ ">1 rut5.... , 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."
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COLORADO MEDICAL LICENSE NUMBER
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VEHICLE SAFETY AND OPERABILITY
CERTIFICATION
Col.:.. c;;.Jr.
Ambulance Service Name: (\'5., E::M f\M~\J \AN t'.- License Plate: 'C'i',"i bf<-Ambulance Number: W\~\C. 2....;
SYSTEMS
Wheels & Tires
eering
Alignment
Suspension
Service Brakes .
Parkin,g Brake .
Driving Lights
Visual Waniing Systems
Audible Warning Systems
~ "slectrical System
}:x.haust System.
'Fuel System
G lass, Mirrors
. Body & Sheet Metal
ACCEPTABLE
<1P .,
<$
d~'
~
~~
)~
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1'\'[0.--'
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NOT ACCEPTAHLE
COMMENTS
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I, ~\Nt~ rrCt -t~. . 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.
MECHANICllME J
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PITKIN couNTY
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BASIC LIFE SUPPORT
REQUIRED EQUIPMENT LIST
SAFETY EOUlPMENT
!:\f\.u One 2-112 lb. or larger ABC fire extinguisher, accessible from the patient compartment and having been
serviced within the last year per NFP A 10 Section 4.
~ One 5 lb. or larger ABC fire extinguisher, accessible from outside the vehicle and having been serviced
within the last year per NFP A 10 Section 4..
~ Two ''NO SMOKING-OXYGEN IN USE" signs, one in cab and one in patient compartment.
.JWL Flashlight, 2-D cell equivalent or better with spare bulb and batteries or charger.
'h1 D Set of 3 reflective warning devices.
rn b One reflective vest, coat or equivalent for each member of the crew normally assigned.
~ At least one "SHARPS" container, clearly labeled and easily accessible in the patient compartment.
~ Restraining devices for all items not in a securable cabinet (D" ')., 'l4 r )L.l/~ \..:>-( J,...,L~k.r
EMERGENCY WARNING EOUlPMENT
fY},o Audible warning device (siren) with at least 2 different tones.
i\Il0 Visual warning devices (lights) with alternating red andlor blue flashing or rotating visible from all sides
simultaneously and clear flashing or oscillating visible from front.
COMMUNICATIONS EOUlPMENT
-~ Mobile VHF radio with appropriate State, Pitkin Couro-j and ir.dividual agency frequencies.
. fVW Mobile UHF radio with appropriate State, Pitkin County, hospital and individual agency frequencies.
l\U) Portable radio with charger andlor cellular phone for back-up communications with dispatch and
hospitals.
~~.-
. I
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,fEDlCAI_ EQUIPMENT AND SUPPLIES
Airway:
l!UL 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.
NIb Bulb Syringe.
I\II,r., Nasopharyngeal airways in pediatric and adult sizes.
rlt6 Oropharyngeal airways in pediatric and adult sizes.
\'lILb Bite stick or equivalent (oropharyngeal airway).
1'-0 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.
rv.-o 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 IOOOcc bag, reservoir and adult mask.
) . .. All mask attachments must be 15mm"
~ Oxygen masks and cannulas capable of delivering oxygen to adults and infants at flows of at least 1-15
LPM. "
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PITKIN couNTY
')
BASIC LIFE SUPPORT
REQUIRED EQUIPMENT LIST
MEDICAL EQUIPMENT AND SUPPLIES
Diagnostic:
~ Blood pressure cuffs in large adult, regular adult, child, infant and neonatal sizes.
Vl/l.b Stethoscopes in adult and pediatric sizes.
~ Pulse oximeter with adult and pediatric sensors.
Immobilization & Splinting:
i~v One lower extremity traction splint.
mu. Upper and lower extremity splints of any type (vacuum, air, SAM, wire, board, etc.).
W:U. Long spine board, vacuum mattress or equivalent with appropriate accessories to immobilize patients
from head to heels.
It\ ,\ One orthopedic stretcher (scoop).
\I\A" Short spineboard, KED or equivalent with appropriate straps to immobilize patients from head to pelvis.
1M II Pediatric spine board or adult spine board adaptable to pediatric use.
lfI:tjl Adult and pediatric sized head immobilization equipment for each long spineboard andlor scoop stretcher
carried.
MA) 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.
)~ Dressings, including but not limited to, trauma, ABD, gauze, occlusive and bandaids per agency needs.
.. ~J :J Sterile bum sheets.
Yh D Povidone and alcohol swabs or equivalent.
fVI.,-.) Adhesive tape, including but not limited to, I" and 2" per agency needs.
lnA. Sterile irrigation solution.
;ostetrical Supplies:
vYlo Sterile OB kit to include: towels, 4x4s, umbilical tape Or cord clamps, scissors, bulb syringe, sterile
blanket and sterile gloves.
V\,w Silver Swaddler and stocking cap or equivalents.
Infection Control:
V'IA...e Exam gloves in small, medium and large sizes.
V\'I.A) Face and eye shields.
~) Fluid-proof gowns with full length sleeves or equivalent.
11M;) Disinfectant spray or wipes for personnel and equipment.
Miscellaneous:
l:2:1:h. Oral glucose.
llUL- Activated charcoal.
...m.o. Heavy duty bandage scissors or shears capable of cuning clothing, belts, boots, etc.
J1/lAL Spill-proof emesis container with at least I liter capacity.
~ universal or separate male and female urinals.
JM.:!L Multi-level. wheeled gurney
)~ Stair chair or equivalent.
~ Blankets.
~ Patient compartment heater.
2
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PITKIN couNTY
",
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APPLICATION
FOR
AMBULANCE VEHICLE PERMIT
~F:RVTCE INFORMA nON
Ambulance Service Name:
f.\.s~~ AfY\~\J\A"-.\c::"," D'ST\'\..\.vr
Office Address:~ 0 l>\. ~ $r~ ,,~\ l ""'"
. STRE fPO BOX ,
(en...)
. Office Communications: 54'4 - \. 5" ~ c
VOICE
u,~,,,,,\T"A.'-- O<-\-o I (A",T\.- ~,=<-o<.. R ~.
\. 'i 1-) CITY STATE
"S'-t '-\ - \ S 1 ~'. .
FAX
fV;pGN c;;,. BII...::.\\
'ZIP CODE
E-MAIL
fNTERNET
-;;HICLE INFORMA nON
fII EO;;> ,Co ;)
Designation: l'Y\<:'co'l M \ \.1 "...~ License Plate: 0 '-... ~ ~ \ VIN: \ \.r ~:r k: 3 <t T "2," ~ 10 3 ~ I 2. ""
Chassis Year: \'1<\1 Make: C"..\-\\C-J'1 Type: I...L II _ III _ 4x4: yes X no_
; . :s T. lh'>ll.- r-nt..e.'i lV\f.>.Q IlllQ... 1 I. I _ .
Insurance Company: \ tIo.\ so c.", .t'olicy Number: ~ Po b ''I 0 I L ~ '[ Expiration:~
Co\.... P \ rx\~
Vehicle Location: : A.1Y\}\\IIAo..1C'_ )'hl........~.....5 0,"" Q '\ CA.~T~.... ("n",-,=.~ tl.n f.\s~ ("~ ~Ilo \\
. . STREETIPO BOX CITY STATE " ZIP CODE
,,~EQUEST FOR W A TVER (include reason for request)
). . '
- . ~ o~~ RL...,..\~ I ",""--n .
'}":?--e / C- j (J..) A/ 1 .-.tJ
SERVICOOlRECTOR's' SIGNATURE
".ICof..,
DATE
(FOR AMBULANCE INSPECTOR'S USE ONLY)
Clear CCIC:
Clear NCIC:
Insurance Card Present: ~
Registration Card Present: ~
-11i..u.- Permit Fee Attached
~ Basic Life Support Required Equipment List Attached
rl\.r., Mechanical Condition Certification Attached
11,,\ Advance Life Support Provider Requi~.ed Equipment Certification Attached
CommentsIRecommendation:
)
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INSPECTOR 'S SIGNATURE
(J~,/r
POsmoN
l&f(-f {Gf
DATE
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PITKIN couNTY
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ADVANCED LIFE SUPPbRT PROVIDER
REQUIRED EQUIPMENT CERTIFICATION
. "
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Ambulance Service Name: ~ <; ~~ .ryv..">\J 1.f-1\..l(<'=C Al\ <;''r./I \C' r AmbulaI?-~e Designation: N\~lC 3
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 chart and drug dosage/equipment size list.
. 't,
'1 A.dult, pediatric and neo-nat~l vascular access supplies ~d equipment as authorized in medical protocols
approved for this ambulance service.
4. Adult, pediatric and neo-natal endotracheal intubation equipment 'as authorized in medical protocols
approved for this ambulance service. . .' ," , , '.
5. Cardiac monitor/defibrillator with printer and adult and'~~diatric monitoring and defibrillat~g capabilities
as authorized in medical protocols approved for this ~bulance' service. .
, ,
"
"'. Pharmacological agents and admini~tration equipmerii ~(i ~i.1~~lie~ as authorized in m~dical' protocols
, ") approved for this ambulance service. "',:' . ,
.,.:..r I . .. '",," I " '.,.
" ',,' , . I .' . ~ ' , '.tL':~: .,,',"1>' I:,' :1 ,:, 'I' ..' " ,'.' . '. I
7. Any additional equipment and supplies needed to 'perfomJother proc;edures as authorized in medical
protocols approved for this ambulance service. .
, '
As Physician Advisor for l\.o;,lle:..l Aivli':>ulAN<.:...e:.. .0\ S~,c:r . I certify that this ambulance
carries the equipment and supplies, listed above and meets the'minimum requirements, established by the State
of Colorado and Pitkin County, to prOVIde medical care and transportation of the sick and injured at the
Advanced Life Support level. Provision of Advanced.Life Support is limited as described in 3-CCR-713-6,
Section 4 "Medical Acts Allowed EMTs and Paramedics."
<30
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PITKIN couNTY
'\
. :'
VEHICLE SAFETY AND OPERABILITY
CERTIFICATION
Col.o. f\ t\t\~
Ambulance Service Name: t\.",,~ ~""\',UlAN~,,,," n\Jtlth!,fense Plate: 02:>", ~\ Ambulance Number: N\~bK "3
.~
SYSTEMS ACCEPTABLE NOT ACCEPTABLE COMMENTS
Wheels & Tires ...~A ,
.,
eering ~--1 .';{J. ' ,
, ,
Alignment Vf"' ,
Suspension .Jf"
Service Brakes <Y
Parking Brake "'-I'r
Driving Lights .j~
Visual Warning Systems --J~ ,
Audible Warning Systems < \~ '
"slectrical System ,,-'~ ' ,
, aust System: ~
'Fuel System ."j~ ' , ,"', . .
,
Glass, Mirrors --~
Body & Sheet Metal \~
\ A ~
"," . ^
I, --CNAJ'~
. 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 mdicated 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.
.:=
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PHONE NUMBER.
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IY\ i=:n\ C oJ
PITKIN couNTY
')
BASIC LIFE SUPPORT
REQUIRED EQUIPMENT LIST
SAFETY EQUIPMENT
~ One 2-1/2 lb. or larger ABC fire extinguisher, accessible from the patient compartment and having been
serviced wi thin the last year per NFP A I 0 Section 4.
h.tc One 5 lb. or larger ABC fire extinguisher, accessible f(om outside the vehicle and having been serviced
within the last year per NFP A 10 Section 4..
fI.I\:b Two ''NO SMOKING-OXYGEN IN USE" signs, one in cab and one in patient compartment.
~'V\A) Flashlight, 2-D cell equivalent or better with spare bulb and batteries or charger.
f11,b Set of 3 reflective warning devices.
f}'1A.) One reflective vest, coat or equivalent for each member of the crew normally assigned.
~ At least one "SHARPS" container, clearly labeled and easily accessible in the patient compartment.
ilt.,) Restraining devices for all items not in a securable cabinet ~!t..r jL.Vt...._ k\ ~
EMERGENCY WARNING EOUlPMENT
~ Audible warning device (siren) with at least 2 different tones.
~ Visual warning devices (lights) with alternating red and/or blue flashing or rotating visible from all sides
simultaneously and clear flashing or oscillating visible from front.
COMMUNICATIONS EOUlPMENT
-~ Mobile VHF radio with appropriate State, Pitkin COunt'j and irldividual agency frequencies.
- (IAn Mobile UHF radio with appropriate State, Pitkin County, hospital and individual agency frequencies.
f\.I..{) Portable radio with charger and/or cellular phone for back-up communications with dispatch and
hospitals.
IN\n
II\'\..t\
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tfEDICAI. EQUIPMENT AND SUPPUES
Airway:
Ilrtc-, 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. (y / ll{
fV\D 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. G/l~
~ Bulb Syringe.
1'fI~ Nasopharyngeal airways in pediatric and adult sizes.
i'lI1,-) Oropharyngeal airways in pediatric and adult sizes.
1'Vl:h Bite stick or equivalent (oropharyngeal airway).
WLo 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.
Mb 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- V alve- Mask with 500cc bag, reservoir and newborn, infant and child masks.
Adult Bag7 Valve-Mask with IOOOcc bag, reservoir and adult mask.
.. All mask anaclunents must be l5rnm..
Oxygen masks and cannulas capable of delivering oxygen to adults and infants at flows of at least 1-15
LPM. '.
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PITKIN couNTY
)
BASIC LIFE SUPPORT
REQUIRED EQUIPMENT LIST
MEDICAl. EOUlPMENT AND SUPPLIES
Diagnostic:
MA Blood pressure cuffs in large adult, regular adult, child, infant and lUU11. sizes.
~ Stethoscopes in adult and pediatric sizes.
Mb Pulse oximeter with adult and pediatric sensors.
Immobilization & Splinting:
JnQ.. One lower extremity traction splint.
ty\D Upper and lower extremity splints of any type (vacuum, air, SAM, wire, board, etc.).
1rJ.!L. Long spineboard, vacuum mattress or equivalent with appropriate accessories to immobilize patients
from head to heels.
\1""; One orthopedic stretcher (scoop).
'nA.) Shon spineboard, KED or equivalent with appropriate straps to immobilize patients from head to pelvis.
~ Pediatric spine board 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 ~l adult through infant sizes.
Wound Care:
~ Bandages, including but not limited to, roller gauze, triangular and elastic per agency needs.
-~ Dressings, including but not limited to, trauma, ABD, gauze, occlusive and bandaids per agency needs.
-- /(t)o. Sterile bum sheets.
Wl,,6 Povidone and alcohol swabs or equivalent.
M..o Adhesive tape, including but not limited to, 1" and 2" per agency needs.
roQ... Sterile irrigation solution.
_ostetrical Supplies:
l\t\,D Sterile OB kit to include: towels, 4x4s, umbilical tape br cord clamps, scissors, bulb syringe, sterile
blanket and sterile gloves.
M() Silver Swaddler and stocking cap or equivalents.
Infection Control:
nib Exam gloves in small, medium and large sizes.
~ Face and eye shields.
,~) Fluid-proof gowns with full length sleeves or equivalent.
Mb Disinfectant spray or wipes for personnel and equipment.
Miscellaneous:
~ Oral glucose.
~ Activated charcoal.
...M:&. Heavy duty bandage scissors or shears capable of cuning clothing, belts, boots, etc.
~ SpiIl-proof emesis container with at least I liter capacity.
~ universal or separate male and female urinals.
~ Multi-level. wheeled gurney
)~ Stair chair or equivalent.
~ Blankets.
~ Patient companment heater.
2
/1)-
PITKIN couNTY
,t^~~'t"-' ~
"
APPLICATION
FOR
AMBULANCE VEHICLE PERMIT
f;ERVTCE INFORMA nON
Ambulance Service Name:
f\s\:>F-o..\ A.~i:'-,\l\ANC'e- ll''''-TA..\C'\'
Office Address::...9.o (\ S j? ~ ~A.U ~ \,\='S.\~"\n'>..L -c '-t <::> t. CA.", l... car""':-l(. R"Q.
. STREETIPO BOX . ( CITY STATE
(~ 1 Co) '- ell ... )
. Office Communications: ?'-\ Y. - l 5" ~ c SLt'-\ - \ ~"l ~
VOICE FAX E-MAlL
A S1H:::I>l' c:c. 't:. \ '" \ I
ZIP CODE
INTERNET
-:HICLE INFORMA nON
"" Sop 1(;.. '-t Co I.e." , n<.\A
Designation: Wl4.t=-L...':%..'D ~~icense Plate: '-\ e ~ A:z, c' VIN: \ C,..:?' ...... \J '?!.,. t-l t'i k \': :~'ol t 1 ~
Chassis Year: \9 ~Q Make: C\...h,=~ '1 Type: I j(. II _ III _ 4x4: yes JL no_
" \S\.P,"'\JLH"=-~ I ,'1.1_.
Insurance ComI>any: I'n~..""~\.,,.. \ ~ ~ ('.0. Policy Number: C:r Yo Co ~ 0 \ 2. & 1 Expiration:~
VehicleLocation:: ~""\.Ilt.:\r..\t'~ 't)ur>-nw-A.\ 0'1'00) \..A.'STLE:.. C'r.l.r~-'L l=l.,,, F\St>~.~ e,'\':'l'
STREETIPO BOX CITY STATE' ZIP CODE
:.-. ~EOUF.ST FOR WAIVER (include reason for request)
).' , ~ '
. . o~e=:n.~\.,\ Dt:= n
~~ W (. JALur-..1
SERVICE IRECTOR S SIGNATURE
le/"'lo':;
. DATE
(FOR AMBULANCE INSPECTOR'S USE ONLY)
Clear CCIC:
Clear NCIC:
Insurance Card Present: hA:>
Registration Card Present: tlh_)
t'\1.t') Permit Fee Attached
ttu? Basic Life Support Required Equipment List Attached
l'\Ah Mechanical Condition Certification Attached
tV';) Advance Life Support Provider Requi!:ed Equipment Certification Attached
Comments/Recommendation:
)
g1i
S crlJK::' ~1l.JNA I u~
~ f...F~A'f rP
POsmON
fe:,{f:!or
/3
PITKIN COU.NTY
'\
J
ADVANCED LIFE SUPPORT PROVIDER
REQUIRED EQUIPMENT CERTIFICATION
, ,
, ,
Ambulance Service Name: A. S p,...j A..IV\ i:'\V\ A....\ C'~~iO\~rtl.\('rAmbul~l:e Designation: M~:r\,(, '1
REQUIRED ALS EOUIPMENT
1. All equipment and supplies listed on the Basic Life Support Required Equipment List.
,
"
2. Pediatric diagnostic equipment, age/weight/vital signs chart and drug dosage/equipment size list.
"2 .<\dult, pediatric and neo-nat~l vascular access supplies and equipment as authorized in medical protocols
approved for this ambulance service.
4. Adult, pediatric and neo-natal endotracheal intubation equipment 'as authorized in medical protocols
approved for this ambulance service. .", . . ,
, .
5. Cardiac monitor/defibrillator with printer and adult and'p~diatric monitoring and defibrillating capabilities
as authorized in medical protocols approved for this Mtbulance'service. .
, ,
". Pharmacological agents and administration equipme~~ IDlq' su;~lies as authorized in m~dical protocols
, ") approved for this ambulance service. . '., .
.-:.' ': ::'1,,:,, ' "', '
" " . ,I i . ~ ' I I,t, ':"':~ ',} \,. t'. .'1 ,:, ',' ..' " .'" .', '
7. Any additional equipment and supplies needed to 'perforIl1oilier procedures as authorized in medical
protocols approved for this ambulance service. .
, '
As Physician Advisor for ~";) p1=-c>..\. A.M \"l., U ~N c: l"" P I sc,',r:-. 'I.~T , 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."
,)
'.
IY
PITKIN couNTY
.,
.)
VEHICLE SAFETY AND OPERABILITY
CERTIFICA nON
Colo. f \ n<.\~
Ambulance Service Name: f:\ ':.f~ -An-\;'\..\.1 i"","-\c'<=., License Plate:!t8?11\ ) 0 Ambulance Number: N\\'lal\, ~
SYSTEMS
Wheels & Tires
STeering
Aligrunent
Suspension
Service Brakes
Parking Brake
Driving Lights
Visual Wanting Systems
Audible Warning Systems
'Slectrical System
Jxh~ust System
'Fuel System
Glass, Mirrors
.!3ody & Sheet Metal
ACCEPTABLE
"z.. -
"../
./. ../T
,/
/.:.;~
I' 'Z _
NOT ACCEPTABLE
COMMENTS
~ .I //.i~
~r JY
~~,-
A/...~/
/.J...~/
/ -
.J, _pi
./. --
"D~/
'V
I / ih~ ./5l._L,I, rJih ,.,)
,", '
.
~
I, . professing to be a motor vehicle mechanic with training in all of the
syst s Hsted above. ha~e 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
lebO tY/IJ?AU-.u-
MECHANIC'S NAME
fJ ilr~v (.c...!'/Y !rOT
AGENCY/COMPANY
17()..-if,).q .-$"~'3
PHONE NUMBER
KJ-II/- g,j-
DATE
.
,
./
/?
.J . ~
PITKIN couNTY
N\~{')\C' i-
'j
BASIC LIFE SUPPORT
REQUIRED EQUIPMENT LIST
SAFETY EOUIPMENT
-Wu:>- One 2-1/2 lb. or larger ABC fire extinguisher, accessi~le from the patient compartplex;t and having been
' serviced within the last year per NFP A 10 Section 4: '
nth One 5 II,.. or larger ABC fire extinguisher, accessible fz:om outside the vehicle and having b,een serviced
within the last year per NFP A 10 Section 4..
I'\u'lTwo "NO SMOKING-OXYGEN IN USE" signs, one in cab and one in patient compartment.
Mn Flashlight, 2-D cell equivalent or better with spare bulb and batteries or charger.
1'\11,,1.) Set of3 reflective warning devices. ,
'(\Il.h One reflective vest, coat or equivalent for each member of the crew normally,assigned.
'I'VL..OAtleast one "SHARPS" container, clearly labeled and easily accessible in the patient compartment.
\'\tto Restraining devices for all items not in a se~urab)e cabinet. (...h-.....,;L c)lo v<... L-;;'f /,.-., lJt<;
EMERGENCY WARNING EOUTPMRNT
'l~ Audible warning device (siren) with at least 2 different tones.
~.o Visual wamingdevices (lights) with alternating red and/or blue flashing or rotatfug visible from all sides
simultaneously and clear flashing or oscillating visible from front.
COMMUNTCA nONS EOTJTPMF:NT
~ Mobile VHF radio with appropriate State, Pitkin County and mdividual agency frequencies.
l'lil~ Mobile UHF radio with appropriate State, Pitkin County, hospital and individual agencyfrequen!=ies. '
"l~ Portable radio with charger and/or cellular phone for back2hp commrmicationswith dispatch and
hospitals.
IfEDICAL EOUIPMENT ANn SUPPT.IES
~ay: . ,
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.
n-,i) Portable suction system with wide bore tubing, rigid pharyngeal curved suction tip and soft catheter .
suction tip with sizes from 5 Fr. to 14 Fr.
M...-..J Bulb Syringe.
Vh.,.) Nasopharyngeal airways in pediatric and adult sizes.
\Nl.o Oropharyngeal airways in pediatric and adult sizes.
I\i'-O Bite stick or equivalent (oropharyngeal airway).
wvO Fixed oxygen system with a minimum storage capacity of 125 cubic feet (Mcylinder) 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 IS cubic feet (D cylinder) and a minimwn
delivery capability for one patient at flows of at least 1-15 LPM.
~'\A.o Infant Bag-Valve-Mask with 500cc bag. reservoir and newborn, infant and child masks.
iJ-"-1j Adult Bag; Valve-Mask with lOOOcc bag. reservoir and adult mask.
I . .. All mask attachments must be 15mm"
~ Oxygen masks and cannulas capable of delivering oxygen to adults and infants at flows of at least 1-15
LPM. '.
1
/(;
PITKIN cou.NrY
'. N\ \15"", c.. '1
)
BASIC.LIFE SUPPORT
, REQUIRED EQUIPMENT LIST
MEDICAL EOUlPMENT AND SUPPLIES
Diagnostic: , ,
11rw Blood pressure cuffs in large adult, regular adult, child..,infant and neonatal sizes.
M\) Stethoscopes in adult and pediatric sizes. '
Vv\...D Pulse oximeter with adult and pediatric sensors.
Immobilization & ,Splinting:
V\,V One lower extremity traction splint.
MA\ Upper and lo~er extremity splints of any type (vacu~, air, SAM, wire, board, etc.).
~ Long spineboard, vacuum mattress or equivalent with'appropriate accessories to immobilize patients
from head to heels. ' ,
V'Y\IO One orthopedic stretcher (s~oop).. , ,
1l.IL., Short spine board, KED or equivalent with appropriate straps to immobilize patients from h?d to pelvis.
./lA..-o Pediatric spineboard or adult spineboard adaptable to, pediatric use.,' .
W ~Adult and pediatric sized head immobilization equiPment for'each long spineboard and/or scoop s?,etchei
carried. ' '. ' .
\VlA) Rigid cervical immobilization collars in tall adult through inf~t sizes.
Wound Care: ','. , '
~ Bandages, including bUt not limited to, ron~rga~7"tiiangUI~' and elastic per agency nee~: ,
)-b.. Dre~sings, including ~ut not limit~d to, ~~a. ~P,,'g~uze' o~c1usive and bandaids per agency needs.
- W'> Stenle burn sheets. . '.' ' ',:',..;',' ' "', ' ' .
~ Povidone and alcohol swabs or equivalent: i"" 1""'::~'I\' ..'. ;'? ,. ; "
M-D Adhesive tape, including but not limited to, l"ana'~" per'agency needs.
~terile irrigation solution. , ' , ,
~ostetrical Supplies: . "
yVl{) Sterile OB kit to include: towels, 4x4s, umbilical tape Or corlc1amps, scissors, bulb syringe, sterile
blanket and sterile gloves.
trlA) Silver Swaddler and stocking cap or equivalents.
Infection Control:
i'lf\A) Exam gloves in small, medium and large sizes. '
1'\.111\ Face and eye shields.
WlAJ Fluid-proof gowns with fu111ength sleeves or equivalent.
W\A) Disinfectant spray or wipes for personnel and equipment.
Miscellaneous:
I
MAl Oral glucose.
iJl.l!) Activated charcoal.
f\t'\AJ Heavy duty bandage scissors or shears capable of cuning clothing, belts, boots. etc.
.'rvI-\) Spill-proof emesis container with at least I liter capacity.
M'i\ universal or separate male and female urinals. .
MN Multi-Ievel,wheeled gurney
)~ Stair chair or equivalent.
~ Blankets.
'I'YI{) Patient compartment heater.
2
/1
PITKIN couNTY
,tf\. ~ lO '5"
",
APPLICATION
FOR
AMBULANCE VEHICLE PERMIT
SERVICE INFORMATION
Ambulance Service Name:
~ 'S p~ ~""u\A.r...I~."" n, ~n'\.\(! T'
OfficeAddress:~o f\.'>~-.1 \IP"u'0 t\-o':>~\t-~l 0"1-0'\ C,c>,.'S.TIIF GR0=4..- \\;" f\~f~ en f',\~1I
' STREETIPOBOX ( . CITY STATE ZIP CODE
('110) ,,'110)
, Office Cominunications: '5 '-\ '-\ \ "'>8 Co <;"'\ ~ - \ '5 1 e; ,
VOICE FAX E-MAIL INTERNET
7.HICLE INFORM A TION
ME:i)\c:. <; G~.I' \rl.<.lI~
Designation: w..!..-..\ "-",, ~"c:~icense Plate: '-\'O,Uc p., ~ '" .
\'IN: \ (,,-\3 T \t ~ '-\ N 'Z. ~e=.. L.\ ~ L\ '\ '"
. .. ,
Type: I JL II _ III _ 4x4: yes i no_
Policy Nwnber. Gr l' Cl (" ~ <:> I t. ~ 1 Expiration:-1..\ \ I '" l"
Chassis Year: \ '1 C1 '-\ Make: C'. \..\. ~"
" '
<iT. i:'A.l L.. ~ n.~ <i
Insurance Company: W\A..."" \ N. ~ \1'.(:; Co
VehicleLocation::I\.'YI.\l,\JbIoJ.Cc. 91.1f=l.n~nj C'"\03 (A.,r\~<:'Qf-"""\.(" 1..". A.s.yi:N Cc, 'i',\1,.,\1
, STREETIPOBOX CITY STATE " ZIPCODE
.:.-. ~QUEST FOR WAIVER (include reason for request)
) , ,
~' , " ~C~;;; ~-=-'1\1\ t:u:-,~
~'(;L7. (, /AIA.-:.J
SERVICE D CTOR S SIGNATIlRE
'o/~/~)
DATE
(FOR AMBULANCE INSPECTOR'S USE ONLY)
Clear CCIC:
Clear NCIC:
Insurance Card Present: .\'\f\{\
Registration Card Present: i\W
Vvi:? Permit Fee Attached
\k.o Basic Life Support Required Equipment List Attached
~ Mechanical Condition Certification Attached
V'vvo Advance Life Support Provider Requi:.ed Equipment Certification Attached
CommentslRecommendation:
)
~~SSIGNATURE
tJtk~1v ~
!'OsmON
\ h\.MJ 0'-;:
OAT
/<{
PITKIN couNTY
'.
\
J
ADVANCED LIFE SUPPbRT PROVIDER
REQUIRED EQUIPMENT CERTIFICATION
, ,
Ambulance Service Name: A.. oS P ~
REQUIRED ALS EOUIPMENT
l\N'.~U 1.Ilo..!'..H'f'. ,.{)\"-T'"R.,1t.:r Ambulant:e Designation: M"=:."I:>\<:;' ~
~ ,
1. All equipment and supplies listed on the Basic Life Support Required Equipment List.
,
2. Pediatric diagnostic equipment, age/weight/vital signs chart and drug dosage/equipment size list.
., A.dult, pediatric and neo-natal vascular access supplies arid equipment as authorized in medical protocols
approved for this ambulance service.
4. Adult, pediatric and neo-natal endotracheal intubation equipment 'as authorized in medical protocols
approved for this ambulance sernce. ' .
5. Cardiac monitor/defibrillator with printer and adult and'p~diat:ric monitoring and defibrillating capabilities
as authorized in medical protocols approved for this ambulance'service.
, '
, .
'>. Pharmacological agents and admini~tration equipme~i:fud. su'ppli~ as authorized in m~dical protocols
-, approved for this ambulance service. '".. . , .' ,
~ \ " " " , . ~, I ,.,~:,.~..-::,:." :7 .", ",.':' , . ""
7. Any additional equipment and supplies needed to 'perfOf1l1:other procedures as authorized in medical .
protocols approved for this ambulance service.
As Physician Advisor for I\~V r::N F\N,~<J\A.N(""" Dl~\~r- . ' I certify that this ambulance
carnes 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."
~q () 9 r
COLORADO MEDICAL l.ICENSE NUMBER
DATE
)
;f!
PITKIN couNTY
r
\
\
'I
VEHICLE SAFETY AND OPERABILITY
CERTIFICATION
Co~. ~'nz..Jo\.
Ambulance Service Name:' 1\') Yl ~ A.l'n'O V \A ...... <:..... License Plate: ~'O'-\ I\!' 0 Ambulance Number: MCJ.::>'H..S
SYSTEMS ACCEPTABLE NOT ACCEPTABLE COMMENTS
Wheels & Tires ,\F
eering ~f= ' ' .
Alignment ",I~ ,
Suspension < ~ --
Service Brakes .JI ,....
Parki~g Brake . . ~r
Driving Lights ~r
Visual Waniing Systems <e\ y.
Audible Warning Systems '- \rr-
Slectrical System ~r . ,
ftxhaust System: .~~
'Fuel System - ;t- o
,
Glass, Mirrors , \-
]3ody & Sheet Metal ~
\ \ -
I, ______cY'a:v\ ~~ . professing to be a motor vehicle mechanic with training in all of the
systems listed above, have evaluated the condition of these systems on the ambulance indicated above and have
determined this ambulance to be in safe operating condition. This evaluation does not warrantee the future
safety and/or operability of this ambulance due to conditions beyond my control.
~~_~(G(~~
RJ-
~~~
Cf7o-~ \
MECHANIC'S NAME
AGENCY/COMPANY
PHONE NUMBER
.
,
go
.~ , .
CY\~:o;:) l~ S
PITKIN couNTY
"j
BASIC LIFE SUPPORT
REQUIRED EQUIPMENT LIST
SAFETY EOUIPMENT
n,u.' One 2- II2 lb. or larger ABC fire extinguisher, accessible from the patient comp~e~t and having been
serviced within the last year per NFP A 10 Section 4:' ,
11M> One 5 Ii,.. or larger ABC fire extinguisher" accessible fI:offi' outside the vehicle and having b,een serviced
within the last year per NFP A 10 Section 4..
~> ' Two "NO SMOKING-OXYGEN IN USE" signs, one in cab and one in patient compartment.
I\A.) Flashlight, 2-D cell equivalent or better with spare bulb and batteries or charger.
~ Set 00 reflective warning devices. ,
WtD One reflective vest, coat or equivalent for each member of the crew normally,assigned.
~ Atleast one "SHARPS" container, clearly labeled and easily accessible in the patient compartment.
'V1/'v0 Restraining devices for all items not in a securable cabinet ' ,
EMERGRNcY W ARNJNG EOUJPMENT
. ~b Audible warning device (siren) with at least 2 different tones.
:11:%> Visual v...arningdevices (lights) with alternating red and/or blue flashing or rotating visible from all sides
simultaneously and clear flashing or oscillating visible from front.
COMMUNTCA nONS EOUJPMFNT '
~ Mobile VHF radio with appropriate State, Pitkin County and individual agency frequencies.
/.AA.v Mobile UHF radio with appropriate State, Pitkin County, hospital and individual agency:frequen!=ies. '
", ~ Portable radio with charger and/or cellular phone for baek2up communications with dispatch and
hospitals.
AEDICAI. EOUIPMFNT ANn SlJPPLlF.S
Airway: "
bll {) 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.
t'u ') 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.
M..0 Bulb Syringe.
IY\.D Nasopharyngeal airways in pediatric and adult sizes.
ffin Oropharyngeal airways in pediatric and adult sizes.
M..O Bite stick or equivalent (oropharyngeal airway).
1vvI"J Fixed oxygen system with a minimwn storage capacity of 125 cubic feet (Mcylinder) and a minimum
delivery capability for three patients simUltaneously at flows ofat 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 IOOOcc bag, reservoir and adult mask.
, . .. All mask attachments must be 15mm"
~ Oxygen masks and cannulas capable of delivering oxygen to adults and infants at flows of at least 1-15
LPM. "
1
fjl
PITKIN couNTY
N\e:..b~<:..."5
')
BASICLIFE SUPPORT
. REQUIRED EQUIPMENT LIST
MEDICAL EOUIPMENT AND SUPPLIES
Diagnostic: . , ,
t'hD Blood pressure cuffs in large adult, regular adult, childi,infa."lt arid .1UftMal sizes.
YVI::l'l Stethoscopes in adult and pediatric sizes.
vv'\.,.DPulse oximeter with adult and pediatric sensors.
Immobilization & ,Splinting:
VV\.D One lower extremity traction ' splint.
,'\!to Upper and lo~er extremity splints of any type (vacu~, air, SAM, wire, board, etc.).
IVvu Long spineboard, vacuum mattress or equivalent wi,th'appropriate accessories to immobilize patients
from head to heels.' . , .
I'\W One orthopedic stretcher (scoop).. , ,
~ Short spine board, KED or equivalent with appropriate straps to immobilize patients from h~d to pelvis.
!'v'Vi> Pediatric spineboard or adult spineboard adaptable to. pediatric use.. '. .
I'1tu Adult and pediatric sized head immobilization ~quipment for'each long spineboard and/or scoop stretcher'
carried. '. ' . ,
MAl Rigid cervical immobilization collars in tall adult tbrough infaift sizes.
Wound Care: . , " . .
~ Bandages, including b~tnot limited to, rolI~r'ga~e"tiiangUlar'and elastic per agency needs: ,
) (V\..D Dre~sings, including but not limited to, trauma, ~.l?,,,g,,!uze; occlusive and bandaids per agency needs.
. VIA'll Stenle bum sheets. '.. ". .. .:.,_, ....' , ,
M.v Povidone and alcohol swabs or equivalent:' ; ..,. I ,:.::~<,; :'; :'1 ;. i : :'.
\4-....0 Adhesive tape, including but not limited to, l"'ana~n per 'agency needs.
~ Sterile irrigation solution. . . .
~ostetrical Supplies: ,.
1'\1\...0 Sterile OB kit to include: towels, 4x4s, umbilical tape Or coM'clamps, scissors, bulb syringe, sterile
blanket and sterile gloves.
nll,v Silver Swaddler and stocking cap or equivalents.
Infection Control:
ltIf-.A Exam gloves in small, medium and large sizes. .'
M b Face and eye shields. '
~ Fluid-proof gowns with full length sleeves or equivalent.
~ Disinfectant spray or wipes for personnel and equipment.
Miscellaneous: .
I
~ Oral glucose.
A1vo Activated charcoal.
h.lt J Heavy duty bandage scissors or shears capable of cuning clothing, belts, boots, etc.
VlMa> Spill-proof emesis container with at least 1 liter capacity.
fl'1 Al universal or separate male and female urinals.
tV\.o Multi-level. wheeled gurney
) VV\..o. Stair chair or equivalent.
rvt-O Blankets.
If"^.-o Patient compartment heater.
2
~~
PITKIN couNTY
N\ b::. \)"\ C' '1
"
,
APPLICATION
FOR
AMBULANCE VEHICLE PERMIT
SERVICE INFORMATION
Ambulance Service Name:
f-\ ~9 E::lll AML!o\.l \A N ':>.=- .D\ S"T'l'l\(, :,
Office Address:.:.9Q ~-;.~~ \J A\li:>" ~-o"""\,\rAL- 0,"+0 \ .c:;.AS"tlc r:..o..~-\c<.. R"O
. STR!ETIPO BOX I ( <:'> 1 ) CITY ST ATE
(~lo) \.l .,.
. Office COmInunications: "5,-\';- \ I)'@:.-c 'S'-'t'-\ - \ 51 ~..
VOICE FAX E-MAlL
A.;s\,~ c~ 81<." II
.... ZIP CODE
INTERNET
-:HICLE INFORMATION
vJ\{~ M~'e.,
Designation: en'" C' 1 1:1 License Plate:
Chassis Year: Iq ~~ Make: c.\-lbJ'1
/ . '5>.. PrwL. ~.....~ ..
Insurance Company: MA.tHN. \5,. \N.S Cc:".
<J\lr
00 z...:BFt
VIN: '~IM4 V 3, \,\ \ K..:F III... 't 1 c.
~
Type: I ~ II _ III _ 4x4: yes ~ no_
Policy Number: t.r-i' c (., 3 Q I l..'C::] Expiration:~
Vehicle Location: : AMih\\"",\\.\I:'''- ~~_n.\X:n..> C,,\ 0:>, l~5TI.1=: '--\l.......:l, i\o f\~f~ Go cH<O\l
. STREETIPOBOX CITY STATE' mCODE
~~QUEST FOR WATVER(incIude reason for request)
).' . , .
P,A"S\f' \ 1!G... ,S:Vp)"-clOr L\~;~N<=>' ii=_ R~I..l~'TE"n
~\n
\,.,\ AI \I ~ ~
R~...".,) I ~ ~o
,
/:? ,,0':1 0AWvILJ
SERVICE DIUCTOR'S SIGNATURE
/O/"'/oS-
DATE
(FOR AMBULANCE INSPECTOR'S USE ONLY)
Clear CCIC:
Clear NCIC:
Insurance Card Present: fVU
Registration Card Present: ftto
~ Permit Fee Attached
1\.40 Basic Life Support Required Equipment List Attached
t.Av Mechanical Condition Certification Attached
~ Advance Life Support Provider Requi:.ed Equipment Certification Attached
CommentsfRecommendation:
)
~S;;;:OR'S SIGNATURE
N~<V ~
POSITION
I ~ lbbl (h~
DATE
~3
PITKIN couNTY
"
'l
VEHICLE SAFETY AND OPERABILITY
CERTIFICA nON
Gr\1T"
Ambulance Service Name: . p.. ~ \" ~ A"" ~-.l \"',...,. (' ;J.icense Plate: oc z.. \'"> rc..Ambulance Number: In C.~K \1
. ,
SYSTEMS ACCEPTABLE NOT ACCEPTABLE COMMENTS
Wheels & Tires ~ .,
eering ~ ' ,
, ,
Alignment ~ ,
Suspension .
~
Service Brakes ~ . .
Parking Brake ~
Driving Lights ~
Visual Wanting Systems ~
Audible Warning Systems ~
Slectrical System .--- .
::Exhaust System: f../""
'Fuel System t/ .... . .
Glass, Mirrors v
!3ody & Sheet Metal t../'" .
. .
I, .f ~ '. professing to be a motor vehicle mechanic with training in ail of the
syste s 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
("- f'V'.-
91tl ').~ S7vS
PHONE NUMBER
~~
.,
PITKIN couNTY
Iv\ eo lC '1--
.)
BASIC LIFE SUPPORT
REQUIRED EQUIPMENT LIST
SAFETY EOUIPMENT
t'kP One 2-112 lb. or larger ABC fire extinguisher, accessible from the patient comp~e~t and having been
serviced within the last year per NFP A 10 Section 4," .
/A,V One SIb: or larger ABC fire extinguisher, accessible fz:om outside the vehicle and having b,een serviced
within the last year per NFP A 10 Section 4.. .
tvtb . Two "NO SMOKING-OXYGEN IN USE" si~, one in cab and one in patient compartment.
/It..:, Flashlight, 2-D cell equivalent or better with spare bulb and batteries or charger.
tvl.A. Set of3 reflective warning devices.
. AlA One reflective vest, coat or equivalent for each member of the crew normally,assigned.
'11,l..1'. 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 EOUTPMRNT
. n1,.O Audible warning device (siren) with at least 2 different tones.
111A) 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.
COMMUNICA nONS EOUIPMENT .
~ Mo~iIe VHF radio with appropriate State, Pitkin County andiildividual agency frequencies.
ilAV Mobile UHF radio with appropriate State, Pitkin County, 'hospital and individual agency frequen!=ies. .
''i~. Portable radio with charger and/or cellular phone for back::up communications with dispatch and .
hospitals.
AEDICAI. EOUIPMENT ANn SUPPLIES
Airway: .
j11l2 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. .
.JM.2... Portable suction system with wide bore tubiriZ,:ri~pharyngeal curved suction tip and soft catheter
suction t~p with sizes from 5 Fr. to 14 Fr(V ~\f ~ . .
~ Bulb Synnge. "_.._._
~ Nasopharyngeal airways in pediatric and adult sizes.
l'\.IA> Oropharyngeal airways in pediatric and adult sizes.
I.Vvo Bite stick or equivalent (oropharyngeal airway).
nt.. Fixed oxygen system with a minimum storage capacity of 125 cubic feet (Mcylinder) and a minimum
delivery capability for three patients simultaneously at flows of at least 1-15 LPM.
lfl/I..D 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.
InJ1.)) Infan~ Bag-Valve-Mask with 500cc bag, reservoir and newborn, infant and child masks.
..:I1b1...- Adult Bag:- Valve-Mask with IOOOcc bag, reservoir and adult mask.
I . .. All mask attachments must be 15mm**
~ Oxygen masks and cannulas capable of delivering oxygen to adults and infants at flows of at least 1-15
LPM. "
d-{
,
PITKIN couiVTY
Me::r.:nL \ 1
)
BASIC LIFE SUPPORT
. REQUIRED EQUIPMENT LIST
MEDICAL EOUIPMENT AND SUPPLIES
Diagnostic: .
-.lIU... Blood pressure cuffs in large adult, regular adult, child;, infant and au L f I sizes.
fi'L6 Stethoscopes in adult and pediatric sizes. .
~\ Pulse oximeter with adult and pediatric sensors.
Immobilization & ,Splinting:
~ One lower extremity traction' splint.
f\Il--C Upper and lo~er extremity splints of any type (vacu~ air, SAM, wire, board, etc.).
Mn.. Long spineboard, vacuum mattress or equivalent wi.thappropriate accessories to immobilize patients
from head to heels.' .
~!U) One orthopedic stretcher (scoop).. . ,
1V\.1J Short spineboard, KED or equivalent with appropriate straps to immobilize patients from h~ad to pelvis.
1\1.. Pediatric spineboard or adult spine board adaptable to, pediatric use..' ,
nW Adult and pediatric sized head immobilization ~quipment for 'each long spineboard and/or scoop stretcher'
carried.","
nt-A Rigid cervical immobilization collars in tall adult through inf~t sizes.
Wound Care: . . .' . , .
~ Bandages, including b~t not limited to, ron~gam;e, ,triangUlar' and elastic per agency needs:
:~Dre~sings, including ~ut not limited to, ~~ ~P,~g<:uze: occlusive and bandaids per agency needs.
. l\,w Stenle bum sheets. ., ' '. .. ::.,..... '.' '. .' . '
~ Povidone and alcohol swabs or equivalent: i.' \. I ,.;:::~}\ :;; ;'7 i i,." ' ..
M.0 Adhesive tape, includIng but not limited to, 1 "3iid~" per'agency needs.
1:IQ. Sterile irrigation solution. ' . .
~ostetrical Supplies: ..
1\1\..0 Sterile OB kit to include: towels, 4x4s, umbilical tape Or coM'c1amps, scissors, bulb syringe, sterile
blanket and sterile gloves.
tllA Silver Swaddler and stocking cap or equival'ents.
Infection Control:
l'\'VC Exam gloves in small, medium and large sizes. '
I\\...<l Face and eye shields.
~ Fluid-proof gowns with fuII length sleeves or equivalent.
iJ'U") Disinfectant spray or wipes for personnel and equipment.
Miscellaneous:
I
. iV\;, Oral glucose.
11,w Activated charcoal.
~ t..> Heavy duty bandage scissors or shears capable of cuning clothing, belts. boots, etc.
I\ILv Spill-proof emesis container with at least I liter capacity.
Mo universal or separate male and female urinals.
fIW Multi-level. wheeled gurney
) ~ '. Stair chair or equivalent.
k/LJ Blankets.
. .
\'IV Patient compartment heater.
2
~~
PITKIN couNTY
.fV\ E.:~ \ c.. I \..~
"
APPLICATION
FOR
AMBULANCE VEHICLE PERMIT
SERVICE TNFORMA nON
Ambulance Service Name: P\ sp~
OfficeAddress:~ ~ A"'~ VA.u ""'1
" STRE !pO BOX
C~ 1 <> 1
" Office Communications: -s-'-\ '-f - \ 5 <6 <>
VOICE
1~tV\~\.ll.<:I.N.C-=- Dl$~\Cr
~~Y'\~L oq 0\ (""''STI ~
" CITY
\.~l-)
"5'-\-'-\ - \5 1 ~
c..~""'''''K ~o. A'S.~~ Co &1\.0 1\
STATE ZIP cODE
FAX
E-MAIL
INTERNET
~HICLE INFORMA nON
W~~GJ~ (,."..
Designation: ~~\<...l\" License Plate: QO,S\3rr'
~: \~~~~~~NLJr\Li~}~
Chassis Year: \9.~e. Make: <:'1-lE-:l./1 Type:I~ 11_ III_
; , ST.1'!'\~\.. fi\"'lo.i1!:..'"
Insurance Company: 1'Wo..~, "'__ \ N S <::..,. Policy Number: G- i () Co ~ () \ Le. 1
4x4: yes.x.. no_
Expiration:~
Vehicle Location: : A"""l'>\.I\A.t'4-;:.e.. ~'\IAn.n::-n5 0'4-""..... C":~:n-h" (:a,<-,'"o\<" r\';'l A"':>fQN Co '&I~ 1\
" STREETIPO BOX CITY STATE' ZW CODE
~ ~OUEST FOR W AlVER(incIude reason for request)
) , ,
" ,
- ,
~~:':>\C' L\.{.",- S'\l f''\l'~~r, L,('>...."I.'5=..:..'"'Rf'-.p"~sTE::.n
No WA.\"=--}
KtE.? "'"IUo::.. n
77_. Q:) (... )A-f.~
SERVICE DIRt'CTOR'S SIGNATURE
IO/t./o')
DATE
(fOR AMBULANCE INSPECTOR'S USE ONLY)
Clear CCIC:
Clear NCIC:
Insurance Card Present: f\:tO
Registration Card Present: lJI,{)
~' Permit Fee Attached
t14.J Basic Life Support Required Equipment List Attached
t1.U. Mechanical Condition Certification Attached
~ Advance Life Support Provider Requi~ed Equipment Certification Attached
ConunentslReconunendation:
)
a4M---
INSPECTOR 'S SIGNATURE
\.s~,---f>
POSITION
(e-(ll('ll)'
DATE
J1
"
i
PITKIN couNTY
VEHICLE SAFETY AND OPERABILITY
CERTIFICATION
c:..", r:
Ambulance Service Name:' f\ ">-vc-..1 ~o\J~ i'I..\~... License Plate:Oo'5'B F-<:..Ambulance Number: N\~<-, C.
SYSTEMS
Wheels & Tires
eering
Alignment
Suspension
Service Brakes
Parking Brake
Driving Lights
Visual Warning Systems
Audible Warning Systems
Slectrical System
:Ex.h~ust System
'Fuel System
Glass, Mirrors
!lody & Sheet Metal
ACCEPTABLE
rr- "
(\~ "
'-~\~
<'it--
~
J?
\(j-
....r
<\~
"W::.-
,~
Jj;;-
~
\v
NOT ACCEPTABLE
COMMENTS
,
, ,
."1, .
,
I
~ /1
.' I ~ I
I, ,,---/~Cr ~ . 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 iDdicated 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
\
.
,
Ic!;tf~
PHONE NUMBER
DATE
f)~
.. ' ~
PITKIN cOuNTY
. M~""t. \\.".
.)
BASIC LIFE SUPPORT
REQUIRED EQUIPMENT LIST
SAFETY EOUJPMENT
~Lt:. One 2-1/2 lb. or larger ABC fire extinguisher, accessible from the patient compartment and having been
. serviced within the last year per NFPA 10 Section 4:' .' ,
~ One 5 Ii>; or larger ABC fire extinguisher, accessible fr:offi' outside the vehicle and having b,een seIViced
within the last year per NFP A 10 Section 4.. ,
~ Two "NO SMOKING-OXYGEN IN USE" si~, one in cab and one in patient compartment.
~t) Flashlight, 2-D cell equivalent or better \>lith spare bulb and batteries or charger.
~ Set of3 reflective warning devices. . '
. .~ One reflective vest, coat or equivalent for each member oftbe crew normally,assigned.
~ Atleast one "SHARPS" container, clearly labeled and easily accessible in the patient compartment
. .~ Restraining devices for all items not in a securable cabinet ' ,
EMERGENcY W ARNlNG EOUTPMRNT
'1\4 Audible warning device (siren) with at least 2 different tones.
Mot> Visual wamingdevices (lights) with alternating red and/or blue flashing or rotatiDg visible from all sides
simultaneously and clear flashing or oscillating visible from front.
COMMUNJCA nONS EOUTPMF:NT
~ Mo~~le VHF rad~o ~th approp~ate State, P~~n CoUIUy and i~dividu~ a~e?cy frequencies. .'
iJM MobIle UHF radIO Wlth appropnate State, PItkin County, 'hOSPltal and mdIVldual agency frequen!=les.
'U~,t Portable radio with charger and/or cellular phone for back::tip communications \>lith dispatch and .
hospitals.
AEDICAL EOUIPMRNT ANn SUPPLIES
~~: .
. Fixed suction system with \>Iide bore tubing, rigid pharyngeal curved suction tip and soft catheter suctton
tip with sizes from 5 Fr. to 14 Fr.
ViLO Portable suction system with wide bore tubjng,ri~aryngeal curved suction tip and soft catheter
suction tip with sizes from 5 Fr. to 14 Fr:' \1:" \Iv ~
Me Bulb Syringe. ~ '.
M..:. Nasopharyngeal airways in pediatric and adult sizes.
lv-t\ Oropharyngeal airways in pediatric and adult sizes.
f).,) Bite stick or equivalent (oropharyngeal airway).
~ Fixed oxygen system with a minimum storage capacity of 125 cubic feet (Mcylinder) 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.
('rtu Infant Bag-Valve-Mask with 500cc bag, reservoir and newborn, infant and child masks.
~ Adult Bag; Valve-Mask \>lith IOOOcc bag, reservoir and adult mask.
.. AU mask attachments must be 15mm"
I n'IU Oxygen masks and cannulas capable of delivering oxygen to adults and infants at flows of at least 1-15
LPM. ~
1
dq
PITKIN couNTY .
. I"I'I~"" co \ \.".
)
BASIC LIFE SUPPORT
. REQUIRED- EQuiPMENT LIST
MEDICAL EOUIPMENT AND SUPPLIES
Diagnostic: . " /_} ,
VVtJ Blood pressure cuffs in large adult, regular adult, child;, infant and ~..l sizes.
nl\ Stethoscopes in adult and pediatric sizes. . l
~ Pulse oximeter with adult and pediatric sensors. '.
Immobilization & ,Splinting: .
-lli.i.L One lower extremity traction splint.
l'Ib Upper and lower extremity splints of any type (vacu~, air, SAM, wire, board, etc.).
.llAD Long spineboard, vacuum mattress or equivalent wi,th'appropriate accessories to immobilize patients
from head to heels.' .
MA'. One orthopedic stretcher (scoop).. . ,
MJ) Short spine board, KED or equivalent with appropriate straps to immobilize patients from h~ to pelvis.
fYI,{) Pediatric spineboard or adult spine board adaptable to, peaiatric use.,' .
'tltJ Adult and pediatric sized head immobilization ~quipment for 'each long spineboard andlor scoop stretcher
carried. ~" . , '
~ Rigid cervical immobilization collars in tall adult through infai;1t sizes.
Wound Care: ','. , .
..llU?. Bandages, including b~t not limited to, roll~rga~e, ,triangUlar' and elastic per agency needs: ,
).~ Dre:sings, including ~ut not limited to, trauma, ~.l?'.'g~uze; o~clusive and bandaids per agency needs.
-- \M.() Stenle bum sheets. .,..... ':'.... ....' ,
.. : . . '.. ,'"
-M- Povidone and alcohol swabs or equivalent: :.",' 1";':>".'0::.", ;'1 i.1 , , '
vVl-O Adhesive tape, including but not limited to, l"aiid~'? per'agency needs.
~ Sterile irrigation solution. ' . .
;ostetrical Supplies: ,.
(Y\,{) Sterile OB kit to include: towels, 4x4s, umbilical tapebr coilcIamps, scissors, bulb syringe, sterile
blanket and sterile gloves.
l\A.o Silver Swaddler and stocking cap or equivalents.
Infection Control:
YY\II.) Exam gloves in small, medium and large sizes. .'
r\I'{\ Face and eye shields. .
t'\tm Fluid-proof gowns with full length sleeves or equivalent.
>>u Disinfectant spray or wipes for personnel and equipment.
Miscellaneous:
I
~ Oral glucose.
\4~ Activated charcoal.
Y\tAl Heavy duty bandage scissors or shears capable of cutting clothing, belts, boots, etc.
\M..O Spill-proof emesis container with at least I liter capacity.
MA) universal or separate male and female urinals.
M1l Multi-level, wheeled gurney
) ~ Stair chair or equivalent.
~ Blankets.
tv\.Cl Patient compamnent heater.
2
~o