HomeMy WebLinkAboutbocc.con.010.2007LICENSE AGREEMENT NO. ~O - °x.00 7
PITKIN COUNTY AMBULANCE LICENSE FOR:
MEDIC 6 (MOUNTAIN AMBULANCE)
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 Iaw 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.C.
RESTRICTIONS/CONDITIONS: Basic Life Support License.
WAIVERS GRANTED: Not applicable.
THIS LICENSE IS VALID FROM: January 1, 2007 through December 31, 2007.
APPROVED BY THE PITHIN COUNTY BOARD OF COUNTY
COMIYQSSIONER S
on /;1- ~O-6 t:
MICHAEL M OWSLEY
Pitkin County Board of County Commissioners
~~ ~~5
{V\E::U\c' , Z-
PITKIN COUNTY
"
APPLICA nON
FOR
AMBULANCE VEHICLE PERMIT
SERVIn: INFORMATION
Ambulance Service Narne: ~slj)",,-,,\ AIV\i3>"~N<+_ cD\s..nl.'I11r
Office Address:
O~.o\.
CITY
('1-c<> )
5'-\'"\ -\-'5. ~ '
FAX
-
STATE
ZIP CODE
Office Communications:
E-MAIL
INTERNlIT
-::HICLF: INFORMA nON
"" <bc> Ie.. ~ c,~.- G;--l..
Designation: ,,^Ce"")MI I i~ License Plate: O~.'-\ - ~FC.. VIN: I F()v.) f- ~ 1 r-'-tLH"'~'"\\ l..}
Chassis Year: Loo"L. Make: foY'l..\:) r~'5o Type:I)L II_ III_ 4x4:yes~ no_
I~uranceCompany:;". f""~l,-f-,n.... ~.&olicyNurnber: &\>010:\<:> \L~l_ Expiration;~
, INI;. c..,
Vehicle Location: : l\N\\~\AI\\<'l= ~-iA.n~..:. o'-t<>.., (""5..(_ C',Q.-=-,.... Ro I\~lli-N C, 81\0 1\
, SlRElITlPO BOX CITY . STATE ~'ZIP CODE
"" ~OlJF.ST FOR WAIVER (include reason for request)
.; \J ONe,.. R?y"'~~
. ,., 1\' ,
~ ~ {')AI'~ /
SERVICE DIRECTOR' SIGNATU~
\l ).11 '" <0
DATE
Clear seIC: , Clear NCIC:
V Permit Fee Attached
V Basic Life Support Required Equipment List Attached
~ Mechanical Condition Certification Attached
\..../ Advance Life Support Provider Requi~ed Equipment Certification Attached
(FOR AMBULANCE INSPECTOR'S USE ONLY)
Insurance Card Present: ~'
Registration Card Present: ........--
CommentsJRecommendation:
)
;::)w FPD N\.,-IJ.- ttJ0/'iAtn e'rvr-
POSITION
lI-gJ -o~
DATE
PITKIN COUNTY
'.
\
I
ADVANCED LIFE SUPPORT PROVIDER
REQUIRED EQUIPMENT ,CERTIFICA nON
Ambulance Service Name; A.. "r ~ I\M~ \J tAwc,,,,,,-' ^\~rn.1. "'..... Ambulance Designation: N'I'~--'\c:.. ~
REOlJIRF.D AI.S F:OUIPMENT
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 service. .
5. Cardiac monitor/defibrillator with printer and adult and 'pediatric monitoring and defibrillating capabilities
as authorized in medical protocDls approved for this ambulance service.
, '
, . '.
'. Pharmacological agents and administration equipment an4 supplies as authorized in medical protocols
') approved for this ambulance service. .
- '"""
'. ' ' , \ 1,.,,',"','1,," 'i', ", ' , ,
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 A..<;'P~ 1\"",.0\.1 lA.w<.=. DI~T"tL\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."
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COLORADO MEDICAL LICENSE NUMBER
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PITKIN COUNTY
')
BASIC LIFE SUPPORT
REQUIRED EQUIPMENT LIST
S~X EOUIPMENT .'
. 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:' .
V One 5 lb. or larger ABC fire extinguisher, accessible f~om outside the vehicle and having ~en 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.
~Jlash1ight, 2-D cell equivalent or better with spare bulb and batteries Dr charger.
Set of3 reflective warning devices. ,
. VOne reflective vest, coat or equivalent for each member ofihe crew normally,assigned.
, 2' i)1least one "SHARPS" container, clearly labeled and easily accessible in the patient compartment.
, . \/'Restraining devices for all items not in a securable cabinet ' "
E~RGENCY WARNING EOUlPMENT . .
, ,Audible warning device (siren) with at least 2 different tones.
1./ 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.
C~MUNICATJONS EQUIPMF.NT ' '
--~ Mobile VHF radio Wlth appropnate State, Pitkin County and mdividual agency frequencies.
,.F v Mobile UHF radio with appropriate State, Pitkin County, 'hospital and individual agency frequen9ies. '
, ' 'VPortable radio with charger and/or cellular phone for back~up communications with dispatch and
hospitals.
.,-
AEDlCAL EQUIPMENT AND SUPPLIES
Airway.' . ,
L/Fixed suction system with wide bore tubing, rigid pharyngeal curved suction tip and soft catheter suction
gp-with sizes from 5 Fr. to 14 Fr. ,
t...--1>ortable suction system with wide bore tubing, rigid pharyngeal curved suction tip and soft catheter
.,$uction tip with sizes from 5 Fr. to 14 Fr.
~e.ulb Syringe.
/'Nasopharyngeal airways in pediatric and adult sizes.
.............Oropharyngeal airways in pediatric and adult sizes.
l:/13ite stick or equivalent (oropharyngeal airway).
I--"tixed oxygen system with a minimIDn 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.
~ilrtable 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.
~Il}fant Bag-Valve-Mask with 500cc bag, reservoir and newborn, infant and child masks.
L./J\dult Bag7 Valve-Mask with IOOOcc bag, reservoir and adult mask. .
) ~. .. All mask attachments must be 15rnmu
Oxygen masks and cannulas capable of delivering oxygen to adults and infants at flows of at least 1-15
LPM. '.
1
1'I\-=9l<:'" '1--
PITKIN COUNTY
I
BASIC LIFE SUPPORT
. REQUIRED EQuiPMENT LIST
.'
MEDICAL EOUIPMENT AND SlJPPUES
Diagp6stic; . ",' . "
V / Blood pressure cuffs in large adult, regular adult, child;. infant arid neonatal sizes.
""\7'/Stethoscopes in adult and pediatric sizes. .
-V Pulse oximeter with adult and pediatric sensors.
ImmDpilization & ,Splinting: '.
V ,One lower ex.tremity traction splint.
V J.]pper and lower ex.tremity splints of any type (vacuum, air, SAM, wire, board, etc.). ,
2 Long spineboard, vacuum mattress or equivaJent wi,th:'appropriate accessories to immobilize patients
from head to heels. .
V One orthopedic stretcher (s~oop). .
V Short spineboard, KED or equivalent with appropriate ~traps to immobilize patients from h~ad to pelvis,
\C:.yediatric spineboard or adult spine board adaptable to, pediatric use.. ' . .
V Adult and pediatric sized head immobilization equipment for 'each long spineboard and/or scoop stretcher'
.carried.' '. . . .
V Rigid cervical immobilization collars in tall adult through infai).t sizes.
Wound Care: " '
l/13andages, including b~t not limited to, roll~rga~~> .triartgular' and elastic per agency needs~ ,
) ;:::7' Dre:sings, including but not limited to, trauma, ~l?','gl!uze, o,cdusive and bandaids per agency needs.
- v~ltenle burn sheets. ",," . . ,'.... " , . .
;:::7'Povidone and alcohol swabs or equivalent:: \. ,.",:::,:.,' ",:1,: i.,
V Adhesive tape, including but not limited to, 1" and ~;' per'agency needs.
i:/iterile irrigation solution. . : ' . ,
~ostetrical Supplies; "
L---Sterile OB kit to include: towels, 4x4s, umbilical tape Or corlclamps, scissors, bulb syringe, sterile
blanket and sterile gloves.
l--Si1ver Swaddler and stocking cap or equivalents.
Infectio~ontrol; ,
l.../"Exam gloves in small, medium and large sizes.
~e and eye shields. .
0"bJid-proof gowns with full length sleeves or eqUivalent.
L/'Disinfectant spray or wipes for personnel and equipment.
Miscellaneous:
I /...,/ Oral glucose.
~~tivated charcoal.' .
\:/'Heavy duty bandage scissors or shears capable of tuning clothing, belts, boots, etc.
~pill-proof emesis container with at least 1 liter capacity.
~niversal or separate male and female urinals.
v-Multi-level, wheeled gurney
) \./Stair chair or equivalent.
\.-/Blankets.
\./Patient compartment heater.
2
~" "' 2""' '","
,
, PITKJ}, COUNTY
, ,
.J , VEHICLE SAFETI AND OPERABILITY
,
CERT leA TlON
.
Am~ulance S~ii:e Name: '# L License Plate;: ' Ambulancie N~ber: f!!e12
,
"
.'
SYSTEMS ACCEPTABLE NO ACCEPTABLE COMMENTS
Wbeels &. T~ .(./ ,
cering ~ "
,
... Alignment C/ ,
Suspension v
Service Brakes ~
Par~B Brake L./
Driving Lights t./'
Visual WB"':"~~ Systems -/
Audible Warning Systems V
'~CalSYstem !/
. . ust. Systeni -V . . 1..- ,
,Fuel System v ' ,
, ..
Glass, Mirrors ----
. Body &. Sheet Metal ~
, .
1. J C1 /McS G ((Ire ~ . professin to be a motor vehicle mechllIlic wiUl training in all oftb
systems listed above. have evaluated the condition of bese systems on the ambulance iDdicate4 above and have
determined this ambulance to be in safe operating con 3ition. This evaluation does not warrantee the future
safety and/or operability of this ambulance due to con litions beyond my control
. f/tKo
~ Ci' ytF 5> r; ( II (c. CiA t/ (0 (JAl '/ Y 9ltJ j)Cl 5/fI. 5' /~j?~
MECHANIC'S NAME AOENCYIC MPAHY I PHONE HUMBER. DAn
.
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'.
.
R>r.>lV>~ 11M> ~I()V j 10, %AM
ASPEN AMBULANCE
9705441578
p. 1
tA t:=i)\<-. J'
PITKIN COUNTY
"
,
APPLICATION
FOR
AMBULANCE VEHICLE PERMIT
SF:RVICF.INFORMATION
Ambulance Service Name: /il.,sobl AJv.,"'v\A....t'E.. O\"'"""',T"
Office Address:cqQ A~l''''''''' ~J>.lL---i \.l""~,,",,,L (:.'-\-01 v.,,<;,,-l_ C.{lF~-'<'l..~ ~'>pc..l cb 8Ite\\
. STRElITlPO BOX '1 C CITY STATE ""ZIP CODE
(Cn~) '11~)
Office Communications: '5'-\'"\- \'S~ " 54--\ - IS1'&
VOICE FAX E-MAIL INTERNlIT
-::HICLE INFORMATION
,,^CP\<...~
Designation: M<' <:"='1 iVI," ~ 4
Cole. {l,..~
License Plate: 0 '1-" A. ~ i
VIN; 'G.-~Tk ~'-\ T?'/ FO~...\.\1-Q
Chassis Year: \<\ q ,
Make: c.1-\~ '1
Type: I.J(. II _ IIl_
4x4: yes -L no_
Expiration: 1.'1 \ / <> 1
Insurance Company: 51'[. ?/\,-.lLf->.... '" ~ f'I\A1'''''''' Policy Number: G.-l" <:I Co ;>, D' 2.. 'b 7
INS, <.P,
Vehicle Location:: I\MI>.J\A....C"'- Y'''....V-9' 0,"\-0> CAH\e..~(....... ~ I\~ Co, '01",,,
SlREEiIPO BOX CITY !irA ZIP CODE
"" :EOUEST FOR W A IVFR (include reason for request)
.J _
~ 0A\~ K.f---PU' -qL~
,"
"
? -ov'LJ~
SERVICOOlRECTOR'S SIGNATURE
I \/1\ ~ '"
DATE
(FOR AMBULANCE INSPECTOR'S USE aNt. Y)
Clear ;:CIC; , Clear NCIC:
../ Permit Fee Attached
vBasic Life Support Required Equipment List Attached
\/'Mechanical Condition Certification Attached
~dvance Life Support Provider Requi~ed Equipment Certification Attached
Insurance Card Present: V
Registration Card Present: v-
CommentslRecommendation:
)
~
~
5 WFfD N',,~J Coorc\ 11\ e.t-c.,
POSITION
1\-61\-0(, "
DATE
INSPECTOR'S SIGNATURE
PITKIN COUNTY
".
,
I
ADVANCED LIFE SUPPOR:T PROVIDER
REQUIRED EQUIPMENT CERTIFICA nON
, ,
Ambulance Service Name: AS~t'-I..l I\IV\,'" \1 ~N 0"" :G\ S'1'n.\ Cr
REOUIRED ALS EOUIPMENT
Ambulance Designation: N\\S.P\(. ~
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.
~ I\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 andpediatrlc 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. '
- 'J,.,,-
. ' \ I 1"'<"";'-" 7. "', . ,
7. Any additional equipment and' supplies needed to'perl"ormother prOl;edures as authorized in medical.
protocols approved for this ambulance service.
As Physician Advisor for po,. ~1> €::W Ai'("\u'-l""'wt"f'.. J:>.1 nt.lt"J\ , 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 ADVI
70'1<(;'-
COLORADO MEDICAL LICENSE NUMBER
II
O{.
DATE
.)
"
lIi\~Q\c'_. ~
PITKIN COUNTY
')
BASIC LIFE SUPPORT
REQUIRED EQUIPMENT LIST
S~Y F:OUlPMENT ..
One 2-1/2 lb. or larger ABC fire extinguisher, accessible from the patient compartpleIlt and having been
'. ~iced within the last year per NFP A 10 Section 4:' .
~one 1&.. or larger ABC fire extinguisher, accessible from outside the vehicle and having ~en serviced
thin the last year per NFP A 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 on reflective warning devices. , '
~ne reflective vest, coat or equivalent for each member of the crew normally,assigned.
, ~ ~least one "SHARPS" container, ~learly labeled and easily accessible in the patient compm;ment.
. . \/"Restraining devices for all items not in a securable cabinet ' ,
EMERGF:NCY WARNING ROlJIPMENT .
, V 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.
COMMUNlCA TIONS EOUlPMRNT
-~obile VHF radio with appropriate State, Pitkin County and individual agency frequencies.
.. l./Mobile UHF radio with appropriate State, Pitkin County, hospital and individual agency frequen!=ies.
, "\ .A'Ortable radio with charger and/or cellular phone for back~hp communications with dispatch and
hospitals.
,'-
AF,DICAT. EQlJIPMRNT AND SlfPPLTF:S
Airway:
\.----'1'ixed suction system with wide bore tubing, rigid pharyngeal curved suction tip and soft catheter Suction
~p with sizes from 5 Fr. to 14 Fr. ,
, Portable suction system with wide bore tubing, rigid pharyngeal curved suction tip .and soft catheter
..,Wction tip with sizes from 5 Fr. to 14 Fr.
\../'Bulb Syringe.
;:::/'Nll5opharyngeal airways in pediatric and adult sizes.
vtlropharyngeal airways in pediatric and adult sizes.
\./Eite stick or equivalent (oropharyngeal airway).
Vfixed oxygen system with a minimwn storage capacity of 125 cubic feet (M cylinder) and a minimum
d~livery capability for three patients simultaneously at flows of at least 1-15 LPM.
L.---1'onable oxygen system with a minimwn storage capacity of 15 cubic feet (D cylinder) and a minimum
~elivery 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 Bag7 Valve-Mask with IOOOcc bag, reservoir and adult mask. .
) ~ ' "All mask attachments must be l5mm..
_ Oxygen masks and cannulas capable of delivering oxygen to adults and infants at flows of at least 1.15
LPM. "
1
,lV\PV' <:... :'> '
PITKIN COUNTY
J
BASICLIFE SUPPORT
. REQUIRED EQuiPMENT LIST
MEDICAL EOUlPMENT AND SUPPLIES
D~iC: . ", '. ,
L J3.t'ood pressur~ cuffs in large ~du~t, r~gular adult, child; infant and neonatal sizes.
\/' Stethoscopes In adult and pedlatrtc SizeS. ..'
;::?Pulse oximeter with adult and pediatric sensors.' "
Immobilization & ,Splinting: .. .,
~.one lower extremity traction' splint. "
V Upper and lo~er extremity splints of any type (vacuum, air, SAM, wire, board, etc.). ,
VLong spine board, vacuum mattress or equivalent with appropriate accessories to immobilize patients
from head to heels. '
V One orthopedic stretcher (scoop). . . " . ' ,
L./ShOl1 spine board, KED or equivalent with appropriate straps to immobilize patients from h~ad to pelvis,
VJediatric spineboard or adult spine board adaptable to, pediatric use..' .
V Adult and pediatric sized head immobilization equipment for'each long spineboard and/or scoop stretcher
carried. " . . ,
L----Rlgid cervical immobilization collars in tall adult through infai).t sizes.
Wound Care; . , " . , ,
. ~. dages, including b~t not limited to, rol1~r ,1iauz.,~, ,triangul. ,31: and elastic per agency needs~ ,
~ ~sings, including but not limited to, trauma, AB!?': g~uze, occlusive and bandaids per agency needs.
. Stenle bum sheets. ., ". . ..' , . " , '
VPovidone and alcohol swabs or equivalent:' ~ .,. I,.;',i,.. ';", :1.: ,,: ' . ,
~dhesive tape, including but not limited to, 1" and i' per agency needs.
~ Sterile irrigation solution. : ' ,
_ostetric Supplies:' . .
terile OB kit to include: towels, 4x4s, umbilical tape br corlclamps, scissors, bulb syringe, sterile
9lanket and sterile gloves.
L./Silver Swaddler and stocking cap or equivalents.
Infection Control;
L..-Exam gloves in small, medium and large sizes.
~ace and eye shields. .
::: Fjuid-proof gowns with full length sleeves or equivalent.
ll/Disinfectant spray or wipes for personnel and equipment.
Miscellaneous:
, VOral glucose.
V Activated charcoal.
L/1!eavy duty bandage scissors or shears capable of cuning clothing, belts, boots, etc.
~Pi1l-prOOf emesis container with at least 1 liter capacity.
universal or separate male and female urinals.
~ulti-level,wheeled gurney
) . Stair chair or equivalent.
~Blankets.
V Patient companment heater.
2
~" ". ,eo, '","
ASPEN AMBULANCE
9705441578
p.1
,
, PlTKo. couNTl'
,
, VEHICLE SAFETI AND OPERABILITY
.) ,
CERT leA TlON
Am~l S "N ,#3. License Platt;: 0;;'S;l3/ Ambulanc~ N~beW-
u ance ervll:e ame:
~So~'CIlI f\'M~lA..~<0'~ ht-,,,",, . . ., .
"
"
SYSTEMS ACCEPTABLE NO ACCEPTABLE COMMENTS
Wheels &. T~res ~ ,
"
eering 17 " ,
,
t- Alignment V ,
Suspension V
Service Brakes v
Parkmg Brake, ' V'
Driving Lights ~
Visual W .. Systems ~
,
Audible Warning Systems ./
Til~cal System r/ ,
, Exha~ System: / .
'Fuel System " V ',.". .
,
Olass, Mirrors i/
Body &. Sheet Metal r/
.
.
I, ':S 0-. J1r\(' ~ G.:! /, 4 ~ . professin to be a motor vehicle mechllIlic wi1h training in all ofth
systems listed above, have evaluated the condition of :hese systems on the ambulance iDdicateil above and have
detennined this ambulance to be in safe operating COil ~ition. This evaluation does not waJTaI1tee the future
safety and/or operability of this ambulance due to con :J.itions beyond my control .
~
~ &1//4; ;Jr If ~ rot//!; /:/ /O'~
~ ().1l1 ~5 (/I) 71t1 ~ ~/Gs~
MECHANIC'S NAME AOENCYIC MPANY PHONE NUMBEIl DATE
)
.
"
.
Rfn1Vf~ T1Mf NrW I 1~'?hAM
W\E.:O\c..'-\
PITKIN COUNTY
"
,
APPLICATION
FOR
AMBULANCE VEHICLE PERMIT
~ERVICF. INFORMATION
Ambulance Service Name: t\sf'~ AM~"'\AN(,__ ,00snUC1r'
OfficeAddress:.c.S4" p..')li'aJ \JA~el l-k>1tp",'''L'::>L\'''' CAsn~C>-:IF-N<"lt.o. l\.')l'......, ~'. ~11:o1I
SlREEiIPO BOX '" CITY STATE ' ZIP CODE
(,\,~) (Ql,a)
Office Communications: ":>'-\'-\- \"5'-& <0 5"\'-\ ."., \!,
VOICE FAX E-MAIL INTERNlIT
-::HICLE INFORMATION
N\(:;s:1l,,-<t Co,=.-V'n<.'tI.
De,signation: vJ "'I~...l ""1> c;,.~<:tq, T icense Plate: ~\!>~ ""!> <:> '
VIN: I G-I~ '*" ~'-INe,K.F 3';",...
Chassis Year: ''1 ~"'- Make: C"~~"'j Type; I JL II _ III_
, .:ir. "A.\lLfi\'\e..~ 1\1~1I~. r
Insurance Company: I....~ C= PohcyNumber: '-A~(;) Co ~ <:> \ 2.-0'1
4x4: yes L no_
Expiration:~
VehicleLocation:: AN\i'I\J\"'~I(,O:- 9"""1).~5 0-+...... C....."T1FCrtf-c-v 1>0>. Asp....IG::, B\~lI
. SlRElITlPO BOX CITY STATE' , ZIP CODE
"" :EOlJF.ST FOR W A IVF:R (include reason for request)
). . '
- l\.\ C\t...l~ R~\..h D~::-l
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;;-;:::::> -'i~ (L.JAi'..... ~
SERVICJi1ilRECTOR'S SIGNATURE
IIWo(.,
DATE
Clear CCIC: Clear NCIC:
/" Permit Fee Attached
V Basic Life Support Required Equipment List Attached
V Mechanical Condition Certification Attached
VAdvance Life Support Provider Requi:.ed Equipment Certification Attached
CommentslRecommendation: Ro.J- I 0 (o,"^,"" c-, " \ (,,-1-J (OF, ~ V l 0, -;J k 1 L 0
(FOR AMBULANCE INSPECTOR'S USE ONLY)
Insurance Catd Present: V
Registration Card Present: v'
Ft"-tAtu.:J
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POSITION
\ \-OZH.\&
DATE
INSPECTOR'S SIGNATURE
PITKIN COUNTY
"
\
i
ADVANCED LIFE SUPPb~T PROVIDER
REQUIRED EQUIPMENT CERTIFICATION
, ,
Ambulance Service Name: (\ 5'f'''''-I
REQUIRED ALS F:OUIPMF:NT
1. All equipment and supplies listed on the Basic Life Support Required Equipment List,
f:\M,",u lAMe"" n. 'T"'~(. r- AmbulaI}o:e Designation: 1\'\12:;),(' &4
.
2. Pediatric diagnostic equipment, age/weight/vital signs chart and drug dosage/equipment size list.
~ l\dult, pediatric and neo-natal vascular access supplies ~d equipinent 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 'pediatric monitoring and defibrillating capabilities
as authorized in medical protocols approved for this ambulance'service.
, '
, . '.
'. Pharmacological agents and administration equipmeIlt and. siJpplies as authorized in medical protocols
'\ approved for this ambulance service. .
-:J "",'
I, , I""""'" ,: 'f. " . , ,
7. Any additional equipment and supplies needed to'perl'onn other proGedures as authorized in medical.
protocols approved for this ambulance service.
As Physician Advisor for At':!>.,......., A/V'I.....\l ~"'t= 01 ~n"'tr . ' I certify that this ambulance
carries the equipment and supplies. listed above d 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 A VI
RE
~Dl'1:3
COLORADO MEDICAL LICENSE NUMBER
(I
,)
M .;." <:.. '-\
PITKIN COUNTY
')
BASIC LIFE SUPPORT
REQUIRED EQUIPMENT LIST
SAFE1:Y EOUIPMENT
VOne 2-1/2 lb. or larger ABC fire extinguisher, accessi?le from the patient compaft!Uel'\t and having been
. ~erviced within the last year per NFP A 10 Section 4.' .
V One 5 lb.. or larger ABC fire extinguisher, accessible froffi' outside the vehicle and having ~en serviced
within the last year per NFP A 10 Section 4..
o Two "NO SMOKING-OXYGEN IN USE" signs, one in cab and one in patient compartment.
VFtashlight,2-D cell equivalent or better with spare bulb and batteries or charger.
rPet of 3 reflective warning devices. '
One reflective vest, coat or equivalent for each member of the crew normally,assigned.
2'Atleast one "SHARPS" container, clearly labeled and easily accessible in the patient compartment.
Restraining devices for all items not 'in a securable cabinet ' .
E~GF,NCY WARNING EOUIPMENT .
. AudIble warrnng 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.
C~UNICA TTONS EQUlPMENT ' '
-~ Mobile VHF radio with appropriate State, Pitkin CoUlllY and individual agency frequencies.
.~ Mobile UHF radio with appropriate State, Pitkin County, hospital and individual agency frequen~ies. '
, ',;,:::7 Portable radio with charger and/or cellular phone for back~up communications with dispatch and .
hospitals.
.,-
ilEDlCAI" EQUIPMENT AND SUPPLIES
Airway: .
l..---'1'ixed suction system with wide bore tubing, rigid pharyngeal curved suction tip and soft catheter Suction
~p with sizes from 5 Fr. to 14 Fr.
(l..'i" Portable suction system with ' bing, rigid pharyngeal curved suction tip and soft catheter
)iUction tip with sizes fr m 5 Fr. to 14 Fr.
I../""Bulb Syringe.
L..---' Nasopharyngeal airways in pediatric and adult sizes.
L.---'Oropharyngeal airways in pediatric and adult sizes.
Bite stick or equivalent (oropharyngeal airway).
L---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.
L----Portable oxygen system with a minimum storage capacity of 15 cubic feet (D cylinder) and a minimum
J'delivery capability for one patient at flows of at least 1-
..fl..lnfant Bag-Valve-Mask with 500cc bag, reservoir an newbom, infan and child masks.
~ Adult Bag: Valve-Mask with IOOOtc bag. reservoir and a
)./' .. All mask attachments must be 15mm* *
~ Oxygen masks and cannulas capable of delivering oxygen to adults and infants at flows of at least I-IS
U~ '
1
PITKIN COUNTY
lV\ r- ~'\c.' 4
J
BASIC.LIFE SUPPORT
. REQUIRED EQUIPMENT LIST
MEDICAL EOUIPMENT AND SUPPLIRS
Diagngstic: ",',
.t.,../' Blood pressure cuffs in large adult, regular adult, child;jnfant and neonatal sizes.
~tethoscopes in adult and pediatric sizes.
Pulse oximeter with adult and pediatric sensors.
ImmDbilization & ,Splinting: '.
v One lower extremity traction splint.
V)Jpper and lower extremity splints of any type (vacu~, air, SAM, wire, board, etc.). ,
v Long spineboard, vacuum mattress or equivalent wi.thappro,priate accessories to immobilize patients
from head to heels. '
V.- One orthopedic stretcher (s~oop)., , '
-0. hon spineboard, KED or equivalent with appropriate straps to immobilize patients from h~ad to pelvis.
~Pediatric spineboard or adult spine board adaptable to, pediatric use..' ,
..... . Adult and pediatric sized head immobilization equipment for 'each long spineboard and/or scoop stretcher
v/'canied. . " . ,
Rigid cervical immobilization collars in tall adult through inflli1t sizes.
Wound Care: ' '
\./Bandages, including but not limited to, roll~r ga~e, ,triangular' and elastic per agency needs~
)...+:;Dre:sings, including but not limited to, tr~uma, Ai3p,: g~uze; occlusive and bandaids per agency needs.
. l.../"Stenle bum sheets. ' . . "", ' ., , , .' ,
V Povidone and alcohol swabs or equivalent:' ~. ,,;:':. ,:..>', .< i ,.." , .' , '
L-/' Adhesive tape, including but not limited to, I " and i' jleragency needs.
1L Sterile irrigation solution. .
,ostetrical Supplies: " .
L/""" Sterile OB kit to include; towels, 4x4s, umbilical tape or cord' clamps, scissors, bulb syringe, sterile
~lanket and sterile gloves.
Silver Swaddler and stocking cap or equivalents.
Infection Control:
L/"Exam gloves in small, medium and large sizes.
~ace and eye shields. .
~luid-proof gowns with full length sleeves or equivalent.
L...--15isinfectant spray or wipes for personnel and equipment.
Miscellaneous: .
,
L---Oral glucose.
!../" Activated charcoal.
~avy duty bandage scissors or shears capable of cutting clothing, belts, boots, etc.
~ill-proof emesis container with at least I liter capacity_
~~~'v.ersal or separate male and female urinals.
. ulti-Ievel. wheeled gurney
) ~.$tair chair or equivalent. .
~ B-lankets.
t/"Patient compartment heater.
2
~" 0' '00' '0'"
ASPEN AMBULANCE
9705441578
p.1
,
,
, PlTKOt COUNTY
,
.j , VEHICLE SAFETI AND OPERABILITY
,
CERTI CATION
. ~'3 '51130 ." L
Ambulance ServiCe Name:~
License Plate;: ' Ambulance Number:
,
, .
,
SYSTEMS ACCEPTABLE NO "ACCEPTABLE COMMENTS
Wheels & Tires ,;/ ,
"
Cering ./ ,..
,
Alignment ,
V'"
SuspCnsion V'
Service Brakes .-/
Par~ Brake ./'
Driving Lights ,../
Visual W .. Systems ,./
,6.udible Warning Systems .../
ilectr:ical System ./ .
. EXhaust System V'" ' ., .
,Fuel System ............. .,'.' ,.
,
Glass, Mirrors ,
v
. Body & Sheet Metal ./
.
I. .~ &..MCS G ;1r:tdV\ . professin , to be a motor vehicle mechanic wifu training in all of th
systems listed above. have evaluated the condition of hese systems on the ambulance iIidicate4 above and have
detennined this ambulance to be in safe operating COil ditioD. This evaluation does not warrantee the future
safety and/or operability of this ambulance due to con iitions beyond my control
. .
16\MfS ~(lf lc.,lJI/\ ~f f/z(~ ( I~ (JAi -If 9)0 9J-D t;7~ ~ !!?/~~
MECHANIC'S NAME AOENCYIC MPANY PHONE NUMBEIl t. DATE
)
.
'.
.
RfnrVfn TrMf ~Inv 1 In. ?hAM
N\ €=,\) 1. t;'S
PITKIN COUNTY
"-
,
APPLICA nON
FOR
AMBULANCE VEHICLE PERMIT
SF:RVICE INFORMATION
Ambulance Service Name: A.sl'.......\ AN\;;>,v\A Ne;;. .-f')\s'n:l\c:r
OfficeAddress:c.9.o jI,,~Ylr.N \lA.I''''~ I:' o""p'''''''-- O'"\-<>I,CA'>'t'le. ~........,,~. ASl'.....l)U:. ~,\"I\
STRElITIP9 BOX '-J (CITY STATE ZIP CODE
~On..) "'''.0)
. Office Communications: "S"i'-\ I '5"~o '>'-{~ - ISle. '
VOICE FAX E-MAIL INTERNlIT
-::HICLF: INFORMATION
M E::J:),,:,. So Co \= PI n<\~
Designation:W~h=<<'1 <=,..,c;.,~icense Plate: ,-\e<\: A.3 <>' VIN: \ GrBT\.< )~ N 'Z.'Rf 2.\$'"\ "\'1
Chassis Year: I" "14 Make: <::",.\ E"'ll 1 Type: I lL II _ III _ 4x4: yes L no_
. . 5)., PAvL.l'w~.s.<tN).l.,.A.'~e;.. 1'1.. _..,
Insurance Company: IN'" C'~ t'olicyNumber: C'ri'<oc,,:>'ol 2.~1 Expiration:~
Vehicle Location;: /\/V\:'>'llA"'._ 9"AAn=.-.j 0'+0" C"A.......\,,_ c."..,-- R.,. ~"''''''-'1 Co 81\01\
SlREETIPO BOX CITY STATE ZIP CODE
"" ~EOlJF:ST FOR WAIVER (include reason for request)
) N' R<'-" -
..ct...l.~ ?'t,J\~""-'~
,','.
77 ~ (../_~)
SERVICE DllltCToR'S SIG ATURE -
l\ 1.1.)-<> I.
DATE
(FOR AMBULANCE INSPECTOR'S USE ONLY)
Clear 91C:. Clear NCIC:
/ Permit Fee Attached
~ Basic Life Support Required Equipment List Attached
~ Mechanical Condition Certification Attached
Insurance Card Present: l..---""
Registration Card Present: L---
~Advance Life Support Provider Requi~ed Equipment Certification Attached
CommentslRecommendation:
)
~~
-
6WF-PD Me<A C.OOrdx\"Qtc,r-
POSITION
tI-'dJ- 00
DATE
INSPECTOR 'S SIGNATURE
PITKIN COU.NTY
'.
.,
i
ADVANCED LIFE SUPPORT PROVIDER
REQUIRED EQUIPMENT CERTIFICATION
, ,
Ambulance Service Name: A."i~~ A.1V\t'n'IA,,\re. .r.l\sn,,<<., Ambul~.:e Designation: M~J-;'c. S
REOUIRF:D ALS F:OUIPMENT
1. All equipment and supplies listed on the Basic Life Support Required Equipment List,
2. Pediatric diagnostic equipment, age/weight/vital sign~ chart and drug dosage/equipment size list.
, i\dult, pediatric and neo-natal 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'pediatric monitoring and defibrillating capabilities
as authorized in medical protocols approved for this ambul~ce' service.
, . . .
~. Pharmacological agents and administration equipme~tanci. supplies as authorized in m'edical protocols
) approved for this ambulance service. . " .. ' , .
...;/ ".' ' : ',. /I!',',.:'", ,", <"'r, ": ' '.".
7. Any additional equipment and supplies needed to perform other procedures as authonzed in medical .
protocols approved for this ambulance service.
As Physician Advisor for {>..'5V'f:N f\M\', u\At..:l, po ..r:> Is~\. \' , 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."
D'7/3
COLORADO MEDICAL LICENSE NUMBER
If /20 66
OATE
J
I'^ E,.'O' <. '5
PITKIN COUNTY
)
BASICLlFE SUPPORT
. REQUIREDEQmPMENT LIST
MEDICAL EOUIPMF:NT AND SUPPLIES
Diagn~: . ",. . ,
~!Uood pressure cuffs in large adult, regular adult, child,jnfant and neonatal sizes.
~~oscopes in adult and pediatric sizes.' .
~ulse oximeter with adult and pediatric sensors. .
Imm~ization & ,Splinting: '
, ne lower extremity traction splint.
~ yPper and lower extremity splints of any type (vacu~, air, SAM, wire, board, etc.). ,
~ong spineboard, vacuum mattress or equivalent wi,thappropriate accessories to immobilize patients
from head to heels. .
V.one orthopedic stretcher (scoop).
\.-"" ~hort spineboard, KED or equivalent with appropriate straps to immobilize patients from h~ad to pelvis,
VPediatric spineboard or adult spine board adaptable to, pediatric use..' ,
V Adult and pediatric sized head immobilization equipment for 'each long spineboard and/or scoop stretcher'
~arried. " '
Rigid cervical immobilization collars in tall adult ihrough inf~t sizes.
,
Wound Care: ' ' . , . .
~andages, including but not limited to, roll~r ga~e, ,triangular' and elastic per agency needS~ ,
) . VDre~sings, including but not limited to, trauma, ~p,:gll:uze; occlusive and bandaids per agency needs.
. l..---"Stenle bum sheets. .,. ".,' '" ' ' , '
~vidone and alcohol swabs or equivaleDt~' : ., ,,;,.:,:: ,; .', .'1,: i. ,
~Mhesive tape, including but not limited to, 1" and ~;' per' agency needs.
0terile irrigation solution. . : ' ,
A)stetrical Supplies:: . , .. .
L/Sterile OB kit to include: towels, 4x4s, umbilical tape br coil clamps, scissors, bulb syringe, sterile
~Ianket and sterile gloves.
Silver Swaddler and stocking cap or equivalents.
Infectigp.-Control: '
VExam gloves in small, medium and large sizes.
Vface and eye shields. .
~uid-proof gowns with full length sleeves or eqilivalent.
VDisinfectant spray or wipes for personnel and equipment.
Miscellaneous: .
, ~al glucose. .
~tivated charcoal.' '
VHeavy duty bandage scissors or shears capable of cuning clothing, belts, boots, etc.
~ll-proof emesis container with at least I liter capacity.
VJ.l~iversal or separate male and female urinals.
v Multi-level, wheeled gurney
) V Stair chair or equivalent.
!../Blankets.
V1>atient compartment heater.
2
f'\ e.., ,"- "
PITKIN COUNTY
')
BASIC LIFE SUPPORT
REQUIRED EQUIPMENT LIST
S~XEQUlPMENT "
One 2-1/2 lb. or larger ABC fire extinguisher, accessible from the patient compa.rtple~t and having been
, - hrviced wi thin the last year per NFP A 10 Section 4:" ,
V One 5 Ib.. or larger ABC fire extinguisher, accessible from outside the vehicle and having b~en serviced
/Within the last year per NFP A 10 Section 4.. "
~ Jwo ''NO SMOKING-OXYGEN IN USE" signs, one in cab and one in patient compartment.
~E1ashlight,2-D cell equivalent or better with spare bulb and batteries or charger.
~et of3 reflective warning devices. , '
, ....... One reflective vest, coat or equivalent for each member of the crew normally,assigned.
. ~ ~east one "SHARPS" container, c~early labeled and easily accessible in the patient compm;ment.
, 'VRestraining devices for all items not in a securable cabinet ' ,
F:MERGENCY WARNING EOlJIPMENT
~ ~dible warning device (siren) with at least 2 different tones, '
-1L'V'isual 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 '
--~obile VHF radio with appropriate State, Pitkin County and individual agency frequencies.
.~bile UHF radio with appropriate State, Pitkin County, hospital and individual agency frequen~ies.
" " ottable radio with charger and/or cellular phone for bac~i.Ip communications with dispatch and
hospitals.
.'-
AEDICAL F.OUlPMENT AND SUPPLIES
Airway: " , ,
~d suction system with wide bore tubing, rigid pharyngeal curved suction tip and soft catheter suction
!iP with sizes from 5 Fr. to 14 Fr. ,
~ottable suction system with wide bore tubing, rigid pharyngeal curved suction tip and soft catheter
~uction tip with sizes from 5 Fr. to 14 Fr.
Vjiulb Syringe.
vNasopharyngeal airways in pediatric and adult sizes.
~ropharyngeal airways in pediatric and adult sizes.
L/" ~ite stick or equivalent (oropharyngeal airway).
l/"" 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.
~rtable oxygen system with a minimum storage capacity of 15 cubic feet (D cylinder) and a minimum
delivery capability for one patient at flows ofat least I-IS LPM.
Vinfant Bag-Valve-Mask with 500cc bag, reservoir and newbom, infant and child masks.
~dult Bag7Valve-Mask with 1000cc bag. reservoir and adult mask.
) /'" .. All mask attachments must be l5mm..
~ Oxygen masks and cannulas capable of delivering oxygen to adults and infants at flows of at least 1-15
UM ,
I
-_-~v 01 2006 10:38
:::...
-----.
-;-;-'
,
ASPEN AMBULANCE 9705441578
p.1
"
1
PITK.a COUNTY
VEHICLE SAFETI AND OPERABILITY
CERTI leA TION
Ambulance Service Name: :1f5
License Plat~:HZqh 3D Ambulanc~ N~ber: /J!/fj S
, ,
SYSTEMS
Wheels & Tires
cering
Alignment
Suspension
Service Brakes
Par~g Brake
Driving Lights
Visual Waniin2 Systems
Audible Warning Systems
'_ lilectrical System
, Exhaust System
'Fuel System
Glass, Mirrors
Body & Sheet Metal
ACCEPTABLE
V,
~ ' ,
~
L.----
~
v
V-
~
1/
t./ '
V
I~
~
i/
NO ACCEPTABLE
COMMENTS
II! <>/1 hr,.ri /l..,,, k.e l,nH C ,~j,
I
,,"t'
I, .::s IA me s. C- I ~ I C fA; . professin to be a motor vehicle mechanic with training in all of the
systcms listed above, have evaluated the condition of hese systcms on the ambulance iIIdicate4 above and have
determined this ambulance 10 be in safe operating con ilion. This evaluation does not warrantee the future
safety anellor operability of this ambulance due to con~tions beyond my controL
t/\ Wi fS
MECHANIC'S NAME
~
C\ I/,~~
fr ! /r: roVtVil
? la 7;;'0<;;?~ S
PHONE NUMBER
/1:.2.216
DATE
)
RECEIVED TIME NOV. I, IO:26AM
PITKIN COUNTY
ME.v\t. '-\
ALs
MThl.i\-~""'.
,
APPLlCA nON
FOR
AMBULANCE VEHICLE PERMIT
fiF:RVICE INFORMATION
Ambulance Service Name: Po. ~ ~ e.J 1\"" t'\. v \ Ao. o.l< ,,," 00\ ~T"R\,,:r
Office Address: <4t? "'''()~ \J P>ooll..-.. ~'S9'rA.'- O~"'\ C"ST\".. <:..t::t,"-<--',-I".:l. A.5,,~ C'a 101....1\
SlREfl:1PO BOX <J r D. ) CITY STATE IP CODE
, I.. '\10) \..~11Q
Office Communications; 5"'-t'-l 15g,c 5'Y.'-I1"S1fl. '
VOICE FAX E~MAlL INTERNET
-::HICLE INFORMATION
M"""",,,-'t C.MN.t\MD) "C-ol<>. ~I"
Designation: IVIC.G'il\-\ I....... License Plate:j''S'i ~'t) I'> VIN: \ Gt-1l..\1<. ?>'t F-1 Wf"o;\1c 11 '5'
Chassis Year; 1'1 ~ e, Make; <:"1-'1 ""'1 Type: I ~ II _ III _ 4x4: yes L no_
, . S,_ ~A"L F=i .......-\ I\o\..o.....,li....
Insurance Company: ')oJ S Co Policy Number: Crt' 0 <0 '0' L. 8. 1 Expiration:~
VehicleLocation:; I\m&J1A.>.1c<= 9"""""V"''''-> <,>,,\Q.3 C"'S.T(~ C'n"",,-\.(.. lto I\~,,~ <::.:::. ~1""1'
SlREETIPO BOX CITY STATE ., ZIP CODE
~ :EOUF.ST FOR W A IVF:R (include reason for request)
), .
- W o.....e:... l<?tU,.........._--..
?-'~ (.J~,,_~
SERVICE 01 CTOR'S SIGNA RE
Ii, {\ I "'n.
, DATE
(FOR AMBULANCE INSPECTOR'S USE ONLY)
Clear <;:CIC: Clear NCIC; Insurance Card Present: ~ Registration Card Present; ~
v" Permit Fee Attached
VBasic Life Support Required Equipment List Attached
~Mechanical Condition Cenification Attached
~dvance Life Support Provider Requi~,ed Equipment Cenification Attached
CommentslRecommendation:
)
_ J"'C/
-
8 w Ff'P ~.J'''e ~l0}uJ' ffi '" 0 t-u--
POSITION
11 ~"J:~ 6(d'
DATE
INSPECTOR'S SIGNATURE
PITKIN COUNTY
,
\
I
ADVANCED LIFE SUPPOg,T PROVIDER
REQUIRED EQUIPMENT CERTIFICA nON
, ,
Ambulance Service Name: A..:. 'f~
REOUIRED ALS EOUIPMENT
1. All equipment and supplies 'listed on the Basic Life Support Required Equipment List.
A^",,,,,, I Ao."i"'F 'n. <rn,,.rAmbulaI).:e Designation: M~\c:. "\
" (M~, "''VI''':>
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 equipinent as authorized in medical protocols
approved for tltis 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 'pediatric monitoring and defibrillating capabilities
as authorized in medical protocols approved for this Mobulance service. '
, '
~. Pharmacological agents and administration equipme~~ and. supplies as authorized in medical protocols
, ') approved for tltis ambulance service. .
...;.J .,'....
.. I , " I"'."" "'.," ",' t', ' "
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 p.....,,~~' A.N\:>'U l..."l'r "" .1'),,~, Q~, ' 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."
PHYSI
, IGNA TURE
? D "t~?
COLORADO MEDICAL LICENSE NUMBER
Ir/b/OC;
DATE
,)
PITKIN COUNTY
l'I\e.oY"-'i
(M~,""'''''~ ")
J
BASIC.LIFE SUPPORT
. REQUIRED EQuiPMENT LIST
MEDICAL EOUlPMENT AND SUPPLIES
Diagnostic: ,
V :Blood pressure cuffs in large adult, regular adult, child;jnfant and neonatal sizes.
~ .Stethoscopes in adult and pediatric sizes.
VPulse oximeter with adult and pediatric sensors.
Immo)ilization & ,Splinting: '
\/ One lower extremity traction'splint.
V Upper and lo~er extremity splints of any type (vacuum, air, SAM, wire, board, etc.). ,
V Long spine board, vacuum mattress or equivalent wi,thappiopriate accessories to immobilize patients
. from head to heels.' .
V One orthopedic stretcher (sc'oop)., ,
V'Short spine board, KED or equivalent with appropriate straps to immobilize patients from h~ad to pelvis,
V'Pediatric spineboard or adult spineboard adaptable to, pediatric use.,' ,
=:JZ: Adult and pediatric sized head immobilization equipment for 'each long spineboard and/or scoop stretcher'
, ~e:~rviCal immobilization collars in ~l adult ihroUgh(nf~)sizes.
Wounsl Care; , ,
V :Bandages, including but not limited to, roll~r gatr1i~, ,triangular' and elastic per agency needs: ,
~re:sings, including but not limited to, trauma, ~p,' g~uze, occlusive and bandaids per agency needs.
. L/Stenle bum sheets. "., ",' " , . ,
[/Povidone and alcohol swabs or equivalellt:' : ". I"':"" ..:.; .", ,),' , "
~b-dhesive tape, including but not limited to, 1" and i' per agency needs.
~Sterile irrigation solution. , . : ' ,
,bstetrical Supplies; " ,
v/Sterile OB kit to include: towels, 4x4s, umbilical tape Or coilclamps, scissors, bulb syringe, sterile
b1anket and sterile gloves.
l/"Silver Swaddler and stocking cap or equivalents.
Infection Control; , '
':::::::';xam gloves in small, medium and large sizes.
\.../"Face and eye shields.
~luid-proof gowns with full length sleeves or equivalent.
V'Disinfectant spray or wipes for personnel and equipment.
Miscellaneous;
I V Oral glucose. '
~;'ctivated charcoal.' '
v' Heavy duty bandage scissors or shears capable of cutting clothing, belts, boots, etc.
L..../~ill-proof emesis container with at least I liter capacity.
L/Upiversal or separate male and female urinals.
t..../'Multi-level, wheeled gurney
) J. Stair chair or equivalent.
~~lankets.
VPatient compartment heater.
2
PITKIN COUNTY
lY\ i:;;s;)' l<::.. 'i
(""TN' ~c. ")
",
BASIC LIFE SUPPORT
REQUIRED EQUIPMENT LIST
S~Y EOUlPMENT '
One 2-1/2 lb. or larger ABC fire extinguisher, accessible from the patient compartple~t and having been
, ,servicedwithinthelastyearperNFPA 10 Section 4:' ,
V One 5 lb; or larger ABC fire extinguisher, accessible fr.om outside the vehicle and having ~en serviced
within the last year per NFP A 10 Section 4..
V Two "NO SMOKING-OXYGEN IN USE" signs, one in cab and one in patient compartment.
\.,/' FlasWight, 2-D cell equivalent or better with spare bulb and batteries or charger.
V~ Set of 3 reflective warning devices.
, v One reflective vest, coat or equivalent for each member of the crew normally,assigned.
'\.,./" At/east one "SHARPS" container, clearly labeled and easily accessible in the patient compartment.
.~ Restraining devices for all items not in a securable cabinet ' "
E~GF:NCY WARNING EOlJIPMENT. '
, :::::::. ~dible warning device (siren) with at least 2 different tones. '
V"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.
, C~UNJCA TIONS EQUlPMENT ' . , ,
-)-7 Mobile VHF radio with appropriate State, Pitkin County and individual agency frequencies.
. ~.Mobile UHF radio with appropriate State, Pitkin County, 'hospital and individual agency frequen~ies. '
", ': 'v Ponable radio with charger and/or cellular phone for back2hp commW1ications with dispatch and
hospitals.
~~.-
IfEDlCAI. EQUIPMF.NT AND SUPPLIES
AirwaV ,
\.../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. ,
V" 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.
v' Nasopharyngeal airways in pediatric and adult sizes.
\../ Oropharyngeal airways in pediatric and adult sizes.
~ Bite stick or equivalent (oropharyngeal airway).
V Fixed oxygen system with a minimwn 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.
VPortable oxygen system with a minimwn storage capacity of 15 cubic feet (D cylinder) and a minimwo
.' delivery capability for one patient at flows of at least 1-15 LPM.
V Infant Bag-Valve-Mask with 500cc bag, reservoir and newbom. infant and child masks.
L/ Adult Bag7Valve-Mask with IOOOcc bag, reservoir and adult mask.
). . **Allmaskanachmentsmustbe15mm"
V Oxygen masks and cannulas capable of delivering oxygen to adults and infants at flows of at least 1-15
LPM. '.
1
~" "' ,"", ,"",
ASPEN AMBULANCE
9705441578
p.1
, PITKIlt COUNTY
. ,
, VEHICLE SAFETI AND OPERABILITY
,) ,
CERTIl leA TION .
-
Ambulance Service Name: #. 1- 1'>75"130 . , . L/
License Plate;: , Ambulance Number.
,
, .
"
SYSTEMS ACCEPTABLE NO ACCEPTABLE COMMENTS
Wl)eels Ik. Tires V ,
"
... cering \...00"'" " ,
,
Alignment ...........- ,
Suspension (....--
Sei'vice Brakes ~
Par~g Brake ~
Driving Lights .........-
Visual W ,. Systems V' ,
Audible Warning SyStems ~
lilectrical System 1/ '
, EXhaust System \/" , , . " .
'Fuel System ....----- ,.",
,
Glass, MiIron' ~
, Body &. Sheet Metal ~
.
I, J lAWlt'.5 G;' k~. ;;.. . professin to be a motor vehicle mechanic with training in all of tb
systems listed above, have evaluated the condition of :hese systems on the ambulance iIidicateil above and have
determined this ambulance to be in safe operating con ition. This evaluation does not warrantee the future
safety and/or operability ohhis ambulance due to con iitions beyond my controL
, f), j f,;'; ( C; )0 )
\/.>v'I,o\ r....IIIv.~ . Gv~fv II Ill/}0
q2/JS;7~~
MECIfANlc's NAME , AOENCYIC MPANY / PHONE NUMBU I f DATE
.
)
'.
-
RrU1Vrn TTMr ~Inv 1 10, ?hAM
1'<\ (;;:UK. <.0
PITKIN COUNTY
"
,
APPLICATION
FOR
AMBULANCE VEHICLE PERMIT
P..>lS..J
, l'<\ \N,AJV\~,
SERVICE INFORMATION
Ambulance Service Name: A.~1>~ AN\f'>"lAot..\r= n. ......"'...~
OfficeAddress:c}.. A..;J;.""'I JAU'(j f.\'OS.'P"'....l O~=I('A.s.r"- ('''''~\<.Ro 1"\S.1l"''''''(~ ~l"'l\
S Ei/PO BOX CITY STATE ZIP'CODE
(~'p) (~lp)
Office Communications: 5'-\ '-'(- \ '5 -e, oC "544 - ,'5 1 ~
VOICE FAX E-MAIL INTERNlIT
-::HICI.F: INFORMATION
i\I\""""c.. (" WTlO"'''''i> ') e,I<>, r<::<vtr,
Designation: IW-(po"1IV1,,,"'Y" License Plate: 'is'''' ~~B D VIN: \ <...-'arK.. \ '"\ F- t rE..L~~, L..'1 \"
Chassis Y ear:J'1 '1 t... Make: C'.~) F"l Type: I x.. II _ III _ 4x4: yes ~ no_
s.' "A-.lLr-,~={ /
InsuranceCompany:""",,-l>.~'= 'N~ ('~ PolicyNumber:<?rf~Co~"1 z.e., Expiration:' \}.ol
VehicleLocation:: AM~"\"'...\r~ <1l\JA.p""-~~ 0'-\-...." er-ST''''(''''~U R" I\~p"""\ Co. l'!,I<01l
. SlRElITlPO BOX " CITY STATE' , ZIP CODE
:.-. :EOlJF.ST FOR WAIVER (include reason for request)
). .
l">.,.", <:: L, {'~ S'-'Pl'l'~'- LI~~""'_ K""P,,<;,"...-:n
"-.)c-.. \t..)A.''''-''.o "RC:;jhJI'I:t~~
,"?' -("/Y cJ.4J'~
SERVIc€DlRECTOR'S SIGNATURE
l I I 1/ Cl I.
DATE
Clear CCIC:
Clear NCIC:
(FOR AMBULANCE INSPECTOR'S USE ONLY)
Insurance Card Present: V Registration Card Present: V'
v' Permit Fee Attached
L/Basic Life Support Required Equipment List Attached
V Mechanical Condition Certification Attached
Advance Life Support Provider Requi~ed Equipment Certification Attached
CommentslRecommendation: Ra,cA \ 0 C ~VV\ M tA .'\ \ U\-1~, -::J \;1 c. po, "<-,,, \0 L.c v e 0\ I D':'>'\tJ 1-\ iff 'r\-<o \
)
CTOR'S SIGNATURE
6lu FflD ",^,:;J,. C~c'rC\\I\QTL""--
POSITION
l\-;l. I- bb"
DATE
PITKIN COUNTY
/'(\~'1."-~
(Inn.! T>.'Y>:sl>)
,-'
-)
BASIC LIFE SUPPORT
REQUIRED EQUIPMENT LIST
SAFETY F:OUIPMENT
l/'" One 2-1/2 lb. or larger ABC fire extinguisher, accessible from the patient compartp1e~t and having been
, serviced wi thin the last year per NFP A 10 Section 4:'
.../ One 5 lb; or larger ABC fire extinguisher, accessible from outside the vehicle and having b~en serviced
,within the last year per NFP A 10 Section 4.. :
V Two "NO SMOKING-OXYGEN IN USE" signs, one in cab and one in patient compartment.
VFlasWight,2-D cell equivalent or better with spare bulb and batteries or charger.
, 1./" Set of3 reflective warning devices. , '
. V One reflective vest, coat or equivalent for each member of the crew nonnally,assigned.
~'At least one "SHARPS" container, clearly labeled and easily accessible in the patient compartment.
, 'VRestraining devices for all items not In a securable cabinet ' "
F:MERGF:NCY WARNING EQUIPMF:NT
V.Audible warning device (siren) with at least 2 different tones.
V Visual warning devices (lights) with alternating red and/or blue flashing or rotating visiblc from all sides
simultaneously and clear flashing or oscillating visible from front.
. C~UNICA TIONS EOTnPMENT ' ' .
-) . Mobile VHF radio with appropriate State, Pitkin County and individual agency frequencies.
- Mobile UHF radio with appropriate State, Pitkin County, hospital and individual agency frequen~ies. '
.., ,', , V Portable radio with charger and/or cellular phone for back:hp communications with dispatch lind
hospitals.
.--
ilEDICAI, EQUIPMENT AND SUPPLIES
Airway: ,
~Fixed suction system with wide bore tubing, rigid pharyngeal curved suction tip and soft cathcter Suction
~ip 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.
L./1'3ulb Syringe.
~asopharyngeal airways in pediatric and adult sizes.
L-.---Oiopharyngeal airways in pediatric and adult sizes.
L..---'Bite stick or equivalent (oropharyngeal airway).
V 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.
L--1'ortable oxygen system with a minimum storagc capacity of 15 cubic feet (D cylinder) and a minimum
,-v(idelivery capability for one patient at flows of at least 1-1
~Infant Bag-Valve-Mask with 500cc bag, reservoir an newbom, infant d child masks.
l../Adult Bag~ Valve-Mask with 1000cc bag, reservoir an a u
) , .. All mask anachments 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 COUNTY
M~\<.,-\"
C""~.fv'>u.)
)
BASIC.LIFE SUPPORT
, REQUIRED EQuiPMENT LIST
MEDICAL EOUIPMENT AND SUPPLIES
DC:OStiC: ", ~
Blood pressur.e cuffs in large ~du~t, r~gular adult, child:jnfant anEnata~~y.zes.
Stethoscopes In adult and pedlatnc SIzeS. ','
v Pulse oximeter with adult and pediatric sensors. .
Immobilization & ,Splinting:
v9ne lower extremity traction'splint.
VUpper and lower extremity splints of any type (vacuum, air, SAM, wire, board, etc.).
...L.::::::: Long spineboard, vacuum mattress or equivalent withappiopriate accessories to immobilize patients
from head to heels. '
V One orthopedic stretcher (sc'oop)., ,
L..--' Short spineboard, KED or equivalent with appropriate straps to immobilize patients from h~ad to pelvis,
v Pediatric spineboard or adult spine board adaptable to, pediatric use.' ,
V Adult and pediatric sized head immobilization equipment for 'each long spineboard and/or scoop stretcher'
carried. " . '
V Rigid cervical immobilization collars in tall adult through inf~t sizes.
Wound Care: ,',
L/Bandages, including but not limited to, roll~rga~e, ,triangular' and elastic per agcncy needs; ,
)-i2f5ressings, including but not limited to, trauina, ABP,'g~uze~ occlusive and bandaids per agency needs.
. Sterile bum sheets. .,. ',:. " . '.' ,
L--Povidone and alcohol swabs or equivalent:': . I' ':'" ,", ',1 " .. '
L----Adhesive tape, including but not limited to, 1" and ~"pei"agency needs.
_ Sterile irrigation solution. '.
,bstetrical Supplics: ,
l--"'-Sterile OB kit to include: towels, 4x4s, umbilical tape br coil clamps, scissors, bulb syringe, sterile
~lanket and sterile gloves.
Silver Swaddler and stocking cap or cquival'ents.
Infection Control:
l./'E:xam gloves in small, medium and large sizes.
L--face and eye shields. '
l-/Fluid-proof gowns with full length sleeves or eqUivalent.
L.----Disinfectant spray or wipes for personnel and equipment.
Miscellaneous:
I L/'Oral glucose.
L,...--'Activated charcoal.
l"/'Heavy duty bandage scissors or shears capable of cutting clothing, belts, boots, ctc.
\..,../~pill-proof emesis container with at lcast 1 liter capacity.
~universal or separate male and female urinals.
vMulti-level, wheeled gurney
) V Stair chair or equivalent.
\:7 Blankets.
V'"Patient compartment heatcr.
2
~" "' ,eo, '0,3'
,
ASPEN AMBULANCE 9705441578
p.1
PlTK. . COUNTY
,)
VEHICLE SAFETI AND OPERABILITY
- CERTllrICA nON' . .'
Ambulance Service Name:' .:rt 1
C(Sfs'3g0 . . .' ;f1, / {,
License Plat~: - Ambulance Number: ,..t1 .
, ,
,
SYSTEMS
Wheels & Tires
eering
Alignment
Suspension
Service Brakes
Par~ Brake
Driving Ligh1B
Visual W .. Systems
Audible Warning Systems
1ilec:trj.cal System
" .EXhaust System
-Fuel System
Glass, Mirrors
. Body & Sheet Metal
ACCEPTABLE
~ "
~ ,,'
v-
c....-----
f ~.
,NO ACCEPTABLE
COMMENTS
'----
L--
_/u/
~
T-;'-- ,
i ___'
f.....-
~
~
, , .-"..
10- '\t:A:m e3 Gr !lte,;; . professin to be a motor vehicle mcchanicwith training in all oftb
systems listed above, have evaluated the condition of bese systems on the ambulance iridicate4 above and have
determined this ambulance to be in safe operating con .ition. This evaluation does not warrantee the future
safety and/or operability of this ambulance due to con litions beyond my control
'5 ~Wlt\ (t-:lJ!q!1~
MECHANI'c'S NAME
PI +hdtc()~/ I
AClENCYIC )MPANY I
9 /0 I/O ~ 7& ~ "/i!Jtt
PHONE NUMBER DATE
)
Rrnlvr~ T1Mr M()V 1 10, ?hAM
PITKIN COUNTY
,
,
APPLICATION
FOR
AMBULANCE SERVICE LICENSE
GENERAL INFORMATION
Ambulance Service Name: ~Q\\ ~~\l~ \=\\'e...\)l'o\-e.~()~s.~~
Doing Business As: ~~~\ ~~ \=\'f ~"t>ro\-~\I.\""",--\:)~~~
Office Address: \0 8<\. :::s\r0~~\'''~ Q,O<<"~,^~~ e.o
STREETIPO BOX CITY ST ATE
Office Communications(<)l<l) '1-0'\ - Q(. t-r ( qlo)~ -0 10 U
VOICE FAX E-MAIL
8\(PL.1
ZIP CODE
INTERNET
SERVICE INFORMATION
Service Area:~\. ~~-s<~ R"...V{\j~J",0.;~ Service Director: S, ,"O*""'\\,0""\" SCl'h
Service Type: PUBLlCK.. PRlVATE_ BU 0<. AU \::>(. EMERGENT~ TRANSFER ~ SPECIALEVENTSv<.
Number of Ambulances Licensed: 'Fo-.:.. ( ""\;
1:>HYSICIAN ADVISOR INFORMATION
.:hysicianAdvisorName:8C'. 0.0..~QJ(\~ ~~
Office Address: 0'-/01 (a."?!!</' (A-Nl..
STREETIPO BOX
jce Communication~m):7l/'f-(Z2B
VOICE
Colorado License Number: ~O"z. b b
Ascfrv<&V7
fNi./-/5""9D
8/0/1
STATE ZIP CODE
fla!d7vtfci hO!-l11tl I/; L () fr(
E-MAlL INTERNET
lj)
FAX
I here y ertify that the information provided In this application is true to the best of my knowledge and belief and
con ai s n wi r I misrepresentation or falsification. Determination that an Ambulance Service License has been issued based
on Is orm on consli. tes grounds for license .revocation, sDspensio of operations and possib iminal prosecution.
PHYSICIAN ADVISOR'S SIGNATURE
(FOR EMS COUNCIL USE ONL V)
Date Received: \ <::) /3 Q I a (. Ambulance Permits Attached:---=l
EMS Council Comments: 1\ \ L '-\ ~l""""'-..r-=-;)
EMS Council Recommendation:
1'A.S\
P -C"i IA )...1MrI::. )
I NAME
I LI, '-II p f"
, DATE
J::MS Council Chairperson Signature:
)
Date Referred to BoCC:
BoCC Action:
Date: