HomeMy WebLinkAboutC03-239 Western Eagle County Ambulance District. a EAGLE COUNTY AMBULANCE PERMIT LICENSURE FOR: July 2003 'TO: Ju1Y 2004 AMBULANCE SERVICE: Western Eagle County Ambulance District P.O. Box 1809. Eagle, Co 81631 Phone 328-1130 Fax 328-1132 VEHICLE YEAR MAKE TYPE #1 2003 Freightliner III #2 2003 Freiehtliner 1II #3 2003 ChevroletIii MEDICAL ADVISOR Diane Hearne, M.D. The inspection of the above named ambulances was made on July 16.2003 by Kelly Liekis, ILN. and Linda Maggiore, RN. This ambulance service has met licensing requirements for Eagle County as established in the resolution as approved by the Board of Commissioners November 1990. ~a INSPECTORS: ~/'~ r l_s./J ~~ I e ly Lields, .N. Date: ri ~/~!~ ~~C~~ ~C?~ ' ~ 3 `i -~ ~ a _. • .. ii` EMERGENCY MEDICAL SERVICES 3 APPLICATION AMBULANCE SERVICE LICENSE Date of Application: c~`~~! 6 ~ a csb 3 _ Name of Ambulance Services: (owner or parent company) 'ES i ~ ~2. l ~ Cz-...s ~ ~I ~, I~.S C ~ ~ r~ ik r Doing Business As:I~E~~~Q.~ '~ l E Cd+.~....s~~-a, ~~--~~~-.J ~ ~' his ~ ~.°~ e.. Address: ~t~. ~ • ~ ~ ~~ E~1-,q Cti C 0. ~/6. ~ ! - Name And Address Of Each Stockholder Or Partner owning 10% Or More of i ne vutsianaing Siock Of i~ne Company Or Having More Tiara A 10°io Ownezs/~ Interest (if applicable): Name, Address And Phone Number of Manager Or Individual Responsible for The Operation Of The Services: _ ~/~.N.A~' ~. ~E/~~ _ l7rS~~ ~cT What Area Of Four County Will Be Served By This Company? Please Attach A Map Indicating The Service Area. c .1rs~-~~e.J G~.°1 C~ Ca _ - List All Location (Central Station And Sub Stations) where ambulances are to be located. Attach Zoning Authorization If 6 How Many Ambulances Do You Operate? 3 If This Is An Initial Application (not a renewal application) Attach ~0 • . ~ 8e ~ • ~ S ~ ; PpRAT E Permit Rest For Each Ambulance. proyjde Name An~~~.ddress O~Y C'es lInsu~~C~attier. 1JumC Of Agent: "r /ki@..~ C . /~.C ilR'~ /~~ p•i-i'/1CH A CERTIFICATE OF INSURANCE TO THIS APPLICATION. 1 I tI~.1~EBY CERTIFY THAT THE INFORMATION PROVIDED IN THIS p1~p1.ICATION IS TRUE TO THE BEST OF MY KNOWLEDGE AND BELIEF AND CONTAINS NO W I1.I.FUL MISREPRESENTATION OR FALSIFICATION. pfTisRMINATION THAT AN AMBULANCE SERVICES LICENSE HAS BEEN ISSUED BASED ON FALSE 1NF~)iiMATION CONSTITUTES GROUNDS FOR LICENSE REVOCATION AND POSSIBLE CRIMINAL PRt)SECUTION. o Q 8 / ~ L ~3 Signature of Agplacrn Date SLJII~Cj.IBED t`.ND AFFIP.AtIED BEFORE ME THIS l~ SAY ~ , ~ 03 III THE COU?~ITY OF ,STATE OF COLO O. ~~~Y ~. ~~`~n ,. _• e o. ®~~~~® • ® r i ~ Signature of Notary O~ ~p F' ~O~' My Commission expires: ~ / ~ ~ / a ~~ (For Office Use Only) paic deceived: / / / Fec I'uid or Excused: Renu~rks: Documents Checked: Receipt #: App~~uval Recommended (Y/N): Date Referred to B.O.C.C. / / / Licensing Agent 7 f A JUL ;16-03 WED O1 ~ 41 PM 834? 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IdUT P'~-LURE Tt) MAIL SIIK'4d NOTICE d;EfALL IiVdl'd'ii: NU rJBLTCATlON OR LIANILTIY OF ANY KIND UPpN'1 IIK COMPANY. -T5. AC1tP1('$ t1A Nt:YRES3:NTATIVE3 ' AUTIIt)1RI~P.tt At:P ~p:N'[ATIVE ACt)RU ~.Q 7/x)0} ' ! ~ I ~,~ : ~ ~ _ , ,-r, t~_ ' ,. i, ._ , 1 . ~ .aaa ..~. ~• Ty ` _ ~.;_ 7:..~. ,~. ~ ~ EAGLE COUNTY, COLORADO• ,.. . '~ i~ `~'-::~ ~ .J ` ~•~'''~^,I(:Y~1 may- .. ._. b r ~ ~ _a_ .~... .1 I I ~ ~:. _ .fie- ~~ ~ • - ,,L., ,.. ~ ~- .. ; ~'.. ~ „~- _~' _~_+.~--+--~°e~ . :-ii , . i i ~ ; ' . ~' ' n~'~ ,-fir ' L- ^.,:. ~: ( f ~ 1 '~• __1 i:r~- ~ -IF^^-~`--~.~ ~rL- i~~I }_ ~I __'1: .. r r . y a.~..i... ~ 1. 7 ~ I 'lam ` ua.a a. ' _h _ _ _'J' L_ ~ : L , . r ~ I a ' l ~• r - ~•''~ gab i. r t ~/` ! ~C l ,. f rJ I i , - I .-1 ^ .. I 1. a - 1 ~G_ • ~ ne<. . -s:.` I , ~ _ ^ - r ,t~ ~ ~` / •'_` ~ b `tie l--F- ~ - ;--- .a. ... .~ ~ ~ ~,,• I • •-- .... .~. .a. .... -- • ~ ..~ T , ` - ~ ~ r w ,1. Contract Bo 2. .c s?~• ~/?s'S 3. 4. a ~t tgZ 1. ~ccountia~ <<--- 2.... 3. a.