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HomeMy WebLinkAboutC04-317 Western Eagle County Ambulance District EAGLE COUNTY AMBULANCE PERMIT LICENSURE FOR: Julv 2004 TO: July 2005 AMBULANCE SERVICE: Western Eagle Countv Ambulance District P.O. Box 1809, Eagle, Co 81631 Phone 328-1130 Fax 328-1132 VEHICLE YEAR MAKE TYPE # 1 2003 Ford III #2 2003 Ford III #3 2003 Ford III MEDICAL ADVISOR: Diane Hearne, M.D. The inspection of the above named ambulances was made on July 30, 2004 by Kristin Diedrich, R.N. and Linda Maggiore, R.N. This ambulance service has met licensing requirements for Eagle County as established in the resolution as approved by the Board of Commissioners November, 1990. INSPECTORS: Il/I /li^- Kristin Diedrich, R.N. Linda Maggiore, R.N. Date: at-... ,~ . ' - ~:MERGENCY MEDICAL SERVICES APPLICATION AMBULANCE SERVICE LICENSE Date of Application: ~ `T1o~ f D Name of Ambulance Ser (owner or parent ~ Doing Business As: ~ vyi~ i u~ rvv c~~ ~ ~ ~- Address: U 1 " Name And Address Of Each Stockholder Or Partner o 10% Or More ivf i ne Outstanaing Siock of ne Company yr riaving iviore iiam A i u o Ownership Interest (if applicable): Name, Address And Phone Num The Ope ion Of The rvices:s What Area Of Your County Will for Served By This Company? Please Attach A Map Indicating List All Location (Central Station And Sub Stations) where ambulances are to be located. A h Zoning Authori7a °°.o~n If Appropriate. How Many Ambulances Do You Operate? If This Is An Initial Application (not a renewal application) Attach n ~ ~ ; PARATE Permit Reque or Each Ambulance. prc~vidName And Ad ~ ss Of Your Insurance Carrier. N„mC Of Agent: Gf1~L /yC~~ ~., A•~•nCH A CERTIFICATE OF INSURANCE TO THIS APPLICATION. ~ I II:IiEBY CERTIFY THAT THE INFORMATION PROVIDED IN THIS A~•~~~,ICATION IS TRUE TO THE BEST OF MY KNOWLEDGE AND BELIEF AND CONTAINS NO Wt[,I.FUL MISREPRESENTATION OR FALSIFICATION. DETERMINATION THAT AN AMBULANCE SERVICES LICENSE HAS BEEN ISSUED BASED ON FALSE INf()IiMATION CONSTITUTES GROUNDS FOR LICENSE REVOCATION AND POSSIBLE CRIMINAL PR()tiECUTION. ~~ at.~~ anyrn of e~..,lir~~..t TlatP ~•o•• rr ,_ ~ Z.ov4- ., m rn ;rm A GTIu4 ~Tl RFFl1R F MF TT-TTC Ln e y , ~ _ , nor ~-r~ COT nv~ry SUIi~~--+"~ " OF ~2 • , STATE O OL O. (Signature of Notary ~ // My Commission expires:/ ~/ ~ b (For Office Use Only) Datc iteceived: ~/ ~/ 0 ~ / Fec i'i~~d or Excused: Remarks: / • ~~ C ~ /~ Documents Checked: ~ Receipt #: App~uval Recommended (Y/N): ~ Date Referred to B.O.C.C. q / ~ / ~/ C~.Q icensing nt 7 . _ - ., TO Steae,~oat Springs • Flat Tops ~~~MtCoy ~ AGLE .oe-•!~ , W'Iderness Area 1 C'~.,e~ Bond Burns `. _ White River ~ OU1 ~1 T~ Nations( Forest ~ 7 tit v~` Stat Bridge ~ -~; 11` I 'f~~ White River ~ '~<<~• National Forest .~ ' ~° ) iN~ cRD _ _ ,%" ,~ c A D Wolcott . ~<<~ ~o `~] . i~~~ ~ ~ J Cnlrru•unlp l:n/f 10 - 6 - Eagle ~' Vail - Gypsum Edwa s- Avon ~ ,o Ia:l~~G' R-Lr~'-• .grrntt'lrrrrd f;alffut~l>~'" ~ -- ._ Ea le'Vpll ' ~' -Q ~ ; U•n 11•l,,<'ud .1'ki : Gz•~ ~ - g I'nfl l;rdf ~ uruu. Dotsero Eagle County ~r•rt•',•t;5t'•kCr,/fC.'u,u,~^ liri/Skl.tltrt To Regional Airport Grand a !s<•r„•<•,• ~„ti•~ ;~Y 5['/.4nrr ~l irf;k•-[ aril ~ Minturn 'unction ~ C.'rntlil/vrrr ;nlf't:nrro~~ ,~, Gnl/'Ct~rrl>•,~ r . n a .: 1f r. ^ ~ White River '-~---•~ '~ ~ -. ~ Gilman National Forest ~-., 1 To Dem .` ~'% ~• Red Cliff ~ ~''~ C;z.~~ ` . ` t Primary coverage in the Roaring Fork: ;~ ~ Basalt Fire and Ambulance District ~ L~~~ I ' S~~ft~rrrt Lrrke , ~ Cu 2~ • EI Jebel ,~~~ p , ~'inc;pnn Rica I ~~~ I ;y Basalt F , G)• Rrrcdt Resen'ofr )fonresfrt c .• Resew r t ~( 1 Y T. A _...... JUL-08-04 THU 11 12 AM 8347 FAX KU. 3032809499 P, 02 k:rl;rl Mcb'~rrlsJrJd )asur;~ncc A~cncy inc. (Iba V ~'rS taf !:(Jlorado a l8 6rrt St, Unit C,' WirJd-ot•, (.'altJr:t;do 80550 ~,'. .r, a'. ;~-., ~":"IS .. ,., p~,,+~~~&;.',`>;~,',:^~:,,:',;'+~n •na~r^u,•1tt,'(MM/DDJY-'1 'rtil3 C,?pZ'f;+ICA'Yti IS J$SUDD A$ A MATI'tiR OF rNFURMq'JtON ONLY AA17 ('ONFt:rLS !Yp Rtt)MTSt1PONTiR;('6RTrPC('AJyI{Ot.DCR TrlrSCl?kT1F1CA't'LOpJ)NOTAMENO FX'fL•NA OR A1,TSR Tra} COVI?RAGB AI'1''URD Dy TI1D PpC1CIRS qr>l.pm. ~.viv~t-~ttra AFr~RDING COVFRAGC COMtPAN\' 1.)'Tl'ER r, C.UMPANY J.F.1"rrwR A Western 1~;agle C'ottr-cy Ambul>aJ~ce Uistriet PU i}nJC 1809 'rn,a ra 7U f"DCJCrfFV'rllA'r' T(11, 'UIdC'rC,' UH' TNSt11tANI:E: I,IYTF.D MYLOW MAYS sY•kN rSiltt;p'r'O'1'FI'E1NSr~R D~~NAMF;D AIWVIs a "~~~ S;~ t`r,'. ` a ' Jxhlt'ATr:p,~{O;1Vrr7ri7'ANl>1NGAkYRT,Qtltki;M&Y'I','Cr''Rn4(1RCONAiTtONQFA;yyCgNTRACTORA'r'tIF:RIIC,'~ ~RTJrF.PULJCVPLRrpp C'F:R'Pl~r('A7"R MqY aF. Y:;~(rtri Q1t MAY ptGU`rArN, ry'rl~; P.Y51,1RANG' AFFORC,I;D EY ry'1•r(S MI.1C'tES nF1t'RIDi',I) lI6! N rS ,Sr+Iw1F:C'T 1U Aldr'l71!'1TriitM51'H1S ..._ [X(').1141f)x~ AN7) Cf1Nt,r'P1QN5 UIr Sl7('H POLrf:l,'1. Llb, ITS SrrOWN MAY HAVr( gEEx R,;OUCr:p NY PArD cLnrrkt5. 1 U ~t'Yr~ owiNSVnANL'~i PUr.ICY NttMxt'sR twl R POI,rCY Fl~l" 1'ULJCY 1;;XP. """"""-^ ^ KATE (MMIDD~YY1 DA7'k (MM/DlalYYj LI6r17;S A r:r'nr:laAr 1.1naR,rrv '~FiSfiL-0002733 111/04 ~~tj 1/11~OS f:M:NERAI,ACGRkt:ATR $ 3,000,000 {^E C'4M'N, C:r;N!'RAJ^ t./AD11.! I Y J'1WD .CAMP/0P ACC. CL.41MlMAl)f: (~ octuR $ 3,000,000 Pros, ~ ADV. rn~unY ~; 1,000,000 [) oovNe«•y ,,; raxrrtAC'1's rrco)'. U _ r:ACJr pcrnRR-'NC'E $ ],000,060 AU'rctM(aCitr,-:6•blAll.IrY '-~--~- f~.-~ ~ VF1S-t.11-10113$0 111104 t[~JANY Aurp ~~ Ar.t,(Jwxrl)AUrc)r st:rrr'nuLrn Aarc,s u111Fnnu'r't,a ~~~ry' xf1N-gvvxw.'h Auros fJ I:AteApt, LJAR,I,tTY ~-.-:z. ,1 p~e~x~wf•M;~.~ I,rntirii~r`v Y},IS, r!_y LiM,r,ttrld,A YUlih[ ,_ ~OTllrtti T'IJAhf t1DraRRr•LA FUr1M 52866 W'UJIJi ktlS' CUMNRN CA7 rON RND r;Mllt,uvrs,l's LrAr,lr.rTY Oitlh;A y ur:sl'xr,'TIONfak OP~;RAI'[ONti71.A7CAllOr purpoke is to vbnw coverages, Eagle t'otJnty ileallh & HuaJan See'~•icey }'U Aox 6(0 1~:atlc, (;f? 8163! 111/OS c:e~Malxr:r, ~wcJ.s Lt>Kr•r (Prr PCI'YUAr aonrLY nvTugY (Orr ArcNlrol) $ r,wro,n t r unmAGt: ,5001170 1il/04 1/005 apt IN -:ACJJ OC;CUII,rrxCE ~ 1,000,000 ACC'Itt•{iATiv ~ 2,000,000 !(1/04 1f1/05 ,p ~ szA7 '• ' ~ •~ a Y, roav r,1M1 rF c V EA('rr ACf"tDCxT ---~ -~--. $100 000 D1SKA.SP PULICY L1M11' ` - 500,000 $ 1001000 ITRNrg ,,,~ JHOlllaa ANY pp'rrJk AROYh; DESGIttfJEO PULICrky DF, CANCEJ,L+D Dr.'F''URE ]ati: ExvrIJATIf,N ~;~~ DA'r!. TtJRx,SOR,'a'Nt: iSSttINC COMPANY Wp,I, KNDT.AVOrt ry'0 M.gtL ~tp DAYS WrtrrTYN ^ xOry~1CL T0'rUE CC:R'rlFrf,.ATF rrfyt,DER NAM1tA 70'JYIE LENT, Dt17 F"AJLUItt; TO MAiL 6tl}COY ~'^ x0'rICRSkIALLtMPO,Sr:rtUODr,JGA9'tt)NQRLIAatJ,tIYOI~ANYI:TNDF~ UNTtrRCOr~iYA.NY,,15, ACEN1'$ UR RM:pREARN [ATJY~:S .4 ArfTliOx17,1:gpl:PRrICY:NTA'!'rVp / ___ ~ 1,000,000 $1,000,000 ~ d, .;~', ~.. `,~~ .. . - v . v "-fit,-%^`.,/- e~ , 4 r.r a., .. ,. ti. ,