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HomeMy WebLinkAboutC05-234 Western Eagle County Ambulance District r1 os. 23,/ - Z 2.- t EAGLE COlJNTY AMBULANCE PERMIT LICENSURE FOR: July 2005 TO: July 2006 AMBULANCE SERVICE: Western Eagle County Ambulance District P.O. Box 1809, Eagle. Co 81631 Phone328-1130 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 19.2005 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:. ~.lL?~ Xsti~ Diedxich, R.N. , Lvv~ rY1~/U JZ/}4J Linda Maggiore, R.N. I OMMISSIONERS APPROVAL TO ISSUE LICENSE Qj't FAX NO, JUj;I\'\UB48~ fI, U~/U - -, ~ -. __ ~ l"'J. 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PA TI: TlIt n/:o (', TIIR lSSlliNG CO~PANV Wll.!, t:NllEA \10(( TO MAt;. ...JJ!..OA YS Wltrnt:N If() nux G(I!) NOTICe: TO '1'11); CI,"1'11I1(.\'1'1: lIo1.1I)/;n NAMtll> 'ro TIIJ: U.H, 1m)' }<'IIlLIJRE TOl\!A1L $1)('11 --~ No-ne); ~IIM.L 1M !'Os I-: NO ClI\!.I"'ATI()N 01\ UAnll.I'I'Y 01' AN h:IND 1\1 Tilt: rOJ\lI'AiW, I, " gaglc, CO 81G31 ~~~):rRESEN"A')"1YE-S / . --.- Alrmorw'llo Rr./'Kt.XIf,NTA TI .; ,\CORO is..s6J~h~---"" ~~_._.~ ~ T ~ 1 '. -,:,-,;,._. " . t' EMERGENCY MEDICAL SERVICES APPLICATION AMBULANCE SERVICE UCENSE Date of Application: ~/2t/as f / Name of Ambulance Services: -L~f, cS &. C I ~ bJ:J7JLL fJ (owner or parent company h erf).. 0.. jfJJ/Y'(f i In.' ,:sk' Doing Business As: '- S;;vYLL 2-s ~bo v' -e. Address: i? {J - ~ I UJ / 2-~ Co '6'/103 / Name And Address Of Each tockholder Or Partner owning 1 % O/More OfTne Outstanding Stock OrThe Company Or Having More T'nan A i 0% I Ownership Interest (if applicable): ~N/ It Name, Address And Phone Number'lofManager Or Indi "dual The Qperation Of The Service~' ^ I G{ , elf e. rver , CY If e w What Area Of Your County Will Be Served By This pany? Please Attach A Map Indicating The sernc~t S @ ~ fJ ]j e<~/F~Jd _ ~-~~ .""-'Yl-.... - , How Many Ambulances Do You Operate? -3 If This Is An Initial Application (not a renewal application) Attach -~ "- .------- - .--.-.- . - e t Nllme Of Agent: ~ A'n'^CH A CERTIFICATE OF INSURANCE TO nus APPLICATION, I J mnEBY CERTIFY THAT THE INFORMATION PROVIDED IN TIllS AlJIJUCATION IS TRUE TO THE BEST OF MY KNOWLEDGE AND BELIEF AND CONTAINS NO WII,I..FUL MISREPRESENTATION OR FALSIFICATION. DETI~RMINA TION THAT AN AMBULANCE SERVICES LICENSE HAS BEEN ISSUED BASED ON FALSE INF()flMA TION CONSTITUTES GROUNDS FOR LICENSE REVOCATION AND POSSIBLE CRIMINAL PROSECUTION. @&_p ~ I ZlLt:6 S:gnature of Appbcant. Date I ~ ~ 2.ooS I SUBSCRIBED A~ AFFIRMED BEFORE ME TInS z:r:..DA Y , M _, IN 1HE COUNTY OF _ 7/D ~ :n::- . STATE OF LORADO, "- Signature 0 My Commission expires:.1iJ ' l...c2..-cb (For Office Use Only) Date Rcceived:~ -I-! Documents Checked: Fec I'uid or~ Receipt #: Renlllrks: ') ~ Apprllval Recommended (y IN):~ Date Refe ed to B.O.C.C.~ -1!eJ .!25../ tLtL/1i dW~iz[ /LIE 7