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HomeMy WebLinkAboutC09-337 Ambulance Service LicensesEAGLE COUNTY LICENSURE DATE: From:_7/1/2009 To: 6/30/2010 AMBULANCE SERVICE: _ Eagle County Health Service District ADDRESS: PO Box 990 Edwards, CO 81 PHONE: 970-926-5270 FAX: _970-926-5235 MEDICAL ADVISOR: _ Diana Hearne, ] (Name/Credentials) The inspection of the above named ambulance service was made on 6/20/2009 by _Staci Bruce, RN 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 May 2007. INSPECTOR(s): (Signature) ~-•-~ [ (Type Name & Credentials)- ci Bruce, RN s (Signature) ~ ~!-~.~ d~"~ (Type Name & Credentials)_Linda Maggiore, RN COUNTY COMMISSIONERS APPROVAL TO ISSUE LICENSE: ~l n'_ :~ ~ ~, ~~ EAGLE COUNTY AMBULANCE VEHICLE PERMIT ~, PERMIT DATE: From: 7/1/2009 To: 6/30/2010 AMBULANCE SERVICE: Eagl e County Health Service District ADDRESS: PO Box 990 Edwards, CO 81632 PHONE: 970-926-527 0 FA X: 970-926-5235 VEHICLE YEAR MAKE TYPE VIN CO-REGISTRATION #1 (780) 2003 Ford III 1FDWE35F33HB42189 906-JUM #2 (781) 2004 Ford III 1FDWE35P15HA12813 876-LWX #3 (782) 2001 Ford III 1FDWE35F61HA57750 . 361-CNC #4(783) 2002 Ford III 1FDWE35F82HA21091 696-FRU #5 (7$4) 2007 Ford III 1FDWE35P27DA96425 677-PVW #6 (785) 2003 Ford III 1FDWE35F53HA60870 871-ILR #7 (786) 2005 Ford III iFDWE35P06HA92445 022-NRG MEDICAL ADVISOR: Diana Hearne, M.D. (Name/Credentials) The inspection of the above named ambulances was made on 5/20/2009 by _Staci Bruce, RN and Linda Maggiore, RN .This ambulance service has met permit requirements for Eagle County as established in the resolution as approved by the Board of Commissioners May 2007. INSPECTOR(s): (Signature) ~~--~ (Type Name & Credentials) i Bruce, RN (Signature) ~e~ v ~~~~~~ >2G'1 (Type Name & Credentials) Linda Maggiore, RN PUBLIC HEALTH ADMINISTRATOR APPROVAL TO ISSUE PERMIT: (Signature) Anne Robinson, Acting PH Director Date: EMERGENCY MEDICAL SE~2VICES APPLICATION AMBULANCE SERVICE LICENSE Date of Application:-M ~~ 1 `~ Name of Ambulance Services: (Owner or parent Company) Eagle County Health Service- District Doing Business As: ~ =~ ~~~~C=c ~(S~(~ Address: P. o. Box 990 Edwards Colorado. 81632 Name And Address Of Each Stockholder Or Pager owning I0% Or More Of The Outstanding Stock Of The Company Or Having More Than A I O% Ownership Interest (if applicable): N/A Name, Address And Phone Number of Manager Or Indiv}'dual Responsible for The Operation Of The Services: J''`a t v N P.O. Box 990 Edwards, Colorado 81632 (970)926-5270 What Area Of Your County Will Be Served By This Company? Please Attach A Map Indicating The Service A~.rea. Easternc~ortion of Eagle County from mile marker 154 on I-70 to mile marker 190 Then north and south to Routh and r1.~ke:~;countyE=..line"s~ f~.~~~ M List A11 Location (Central Station And Sub Stations) where ambulances are to be located. Attach Zoning Authorization If Appropriate. Edwards Bulling (headquarters) 1055 Edwards Village Blvd. Edwards CO. Vail Building 181 W, Meadow Drive Vail, CO, _~~ i3i~l W r~l ~.r, i ~ S~ i ~ ~ t3 ~.-~C~F P~ ~A~ I~_ t~t.~ ~-1 a l~~" z i ~ s~~ ~ ~ _ How Many. Ambulances Do You Operate?~~` ~>~ 4~~ F,4-c-c-- Z,3c7~~ If This Is An Initial Application (not a renewal application) Attach A SEPARATE Permit Request For Each Ambulance. Provide Name And Address Of Your Insurance Carrier: See at.tached::Certfcat:e. cf Insurance Name Of Agent: ATTACH A CERTIFICATE OF INSURANCE TO THIS APPLICATION. I HEREBY CERTIFY THAT 'THE INFORMATION PROVIDED IrT THIS APPLICATION IS TRUE TO THE BEST OF MY KNOWLEDGE AND BELIEF AND CONTAINS NO WILLFUL MISREPRESENTATION OR FALSIFICATION. DETERMINATION THAT AN AMBULANCE SERVICES LICENSE HASBEEN ISSUED BASED ON FALSE INFORMATION CONSTTTUTES GROUNDS FOR LICENSE REVOCATION AND POSSIBLE CRIMINAL PRQSECUTION. P~~ ~ 1~~~~I Si afore of Applicant .Date X009 SUBSCRIBED AND AFFIRMED BEFORE ME THIS la DAY m , 1~9-;, IN THE COUNTY OF ~ ~ ,STATE OF COL DO. ~~~~ly1CA L, j~4 . 4'.+' ti,~0''.. ~'~~~'~.~5•'~~...w,.•~''o$`;~~~ Signature ofNotary ,''~O~l~ ~~ `,`` My Commission expires: o~ / e3 / X01$ (For Office Use Only) Date Received: / / / Fee Paid or Excused: Documents Checked: Receipt #: Remarks: Approval Recommended (Y/N): Date Referred to B.O.C.C. / / / Licensing Agent ~'OR4M CERTIFICATE OF LIABILITY INSURANCE 05/12/2009) PRC?DUCER (303)368-5757 FAX (303)368-5863 T. Charles Wilson Insurance Services 2260 So. Xanadu Wa # 280 Y THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Aurora, CO 80014 INSURERS AFFORDING COVERAGE NAIC # INSURED Eagle County Health Service District INSURER A: Arch Insurance Company DBA: Eagle County Emergency Services Hospital INSURER B: P 0 Box 990 INSURER C: Edwards, CO 81632 INSURER D: INSURER E: RnVFRAGFS THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR DD' TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS GENERAL LIABILITY MEPK07362100 01/01/2009 01/01/2010 EACH OCCURRENCE $ 1 ~ 000 r Qp X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ 100 ~ 00 CLAIMS MADE ~ OCCUR MED EXP (Any one person) $ 5 ~ QQ A X Professional PERSONAL & ADV INJURY $ 1 r QQQ r QQ Ll abll 1 ty GENERAL AGGREGATE $ 10 r QQQ ~ QQ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS -COMP/OP AGG $ 10 r QQQ r QQ POLICY PRO LOC JECT AUT OMOBILE LIABILITY MEPKU73621UU O1/U1/2UU9 O1/U1/2UlU COMBINED SINGLE LIMIT $ X ANY AUTO (Ea accident) 1' QQQ' 00 ALL OWNED AUTOS 00DILY INJURY $ SCHEDULED AUTOS (Per person) A X HIRED AUTOS BODILY INJURY X NON-OW NED AUTOS (Per accident) $ PROPERTY DAMAGE (Per accident) $ GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY MEUM07170200 Ol/Ol/Z009 01/01/2010 EACH OCCURRENCE $ 1, 000 , 00 X OCCUR ~ CLAIMS MADE AGGREGATE $ 3 ,QQQ , OO A $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION AND WC STATU- 0TH- EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? E.L. DISEASE • EA EMPLOYE $ If yes, describe under SPECIAL PROVISIONS below E.L. DISEASE -POLICY LIMIT $ OTHER DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES /EXCLUSIONS ADDED BV ENDORSEMENT /SPECIAL PROVISIONS Eagle County P.O. Box 850 Eagle, CO 81632 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL lO DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILRY OF ANV KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE ACORD 25 (2001/08) ©ACORD CORPORATION 1988 IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. ACORD 25 (2001/08) d 0 --- -•r-' ~` `~" _ ~ y ~. ~ ®, '- d ~ ~ ii. ~ = a~ , - ~ y ~ a a ~~ ~ z ,,._ ~ ~ t , , ~ L ~ o _ C: ~ ~~ ~ ~ , .. a > h~ z (a ~,Q ~~~ dy Q '• r (J ~ `~ ~ `` ~ ~ ~ L~rl~'~, Gr•eeiz• ~ ,~ ~ ~ •_ V1 Z:Z7 T ~ •y_ -~ 00 ~ m ~ r- c/'f ~ d ~1" ~' 0 ~ ~ t ~ ~ 1 W L ~ a d L 4 ~ L w _ ~ N ~ .ar ~ ~"~ r=. ~ L i 'O •7 ~ Z v ~ ~ •~ m v a ~ ~~ a>= .Q ;, ~., ~ I v=i ~ ° ~ G u~ d ~ r ~ .. , a~i ~ fl.. ~, V i ~ a ,~ ~ ` i p ~~\ • r-. _ '~Y t 1 4.~ V L d _ r,~ O^ ^.1 e } .~ ' O •~~ ~..1 I w~' a .v cc ~ r% ~ a f q s.°_ J cr; o. d a~ n'' .v O W `y ~ ~ . `, . ~ ~ O ~ ^ O = +- ~ ~ "' Eagle County Health Service District STAFF DIRECTORY Physician Advisor Hearne, Diana MD 328-5780 rrima rnone other Phone Pager Extension Administrative Morrison, Fred 524-0620 390-9024 t 390-3733 106 Brandes, Peter 328-0423 390-0543 / 376-6816 v-303 / e-134 Dunn; Will 4q1-3968 720-323-3454 112 McRory, Cathy 328-9494 390-7314 / 390-199 110 Ross; Veronica 638-1088 390-7268 101 Turnbull, Elaine 926-5173 390-7285 105 Var-ela, Sand `569-3159 103 Shff Supervisors 390.4479 ' 304- 3radford, Jim 827-4203 -376-1812 211 Oulac, Kyle 376-8176 214 Crause, Doug 303-526-9518 390-9104 208 Velson, Kim 926-2347 470-3788 748-8359 213 Ful!-time t3urneft, Lizzie 376-1833 845-1057 748-7136 2i5 Coleman, Megan 808-346-0181 Cox, Dan 524-3468 376-3802 203 Egan, Lauren 688-0819 748-7171 Foster, Doug 476-4475 970-401:-3593 207 Harmsen, Scott 513-1335 333-0397 217 Hazard, Brenda 845-9343 74$-8366 204 Kane, Graham 389-1471 748-8340 209 Lacy, Darren 328-1714 '^ 376-1886 204 Lambertus, Missy 719-486-0253 390-7867 216 Marsh, Chris 777-1137 471-4399 202 Mauro, Josh 390-2920 McGann; Jim 471-9443 319-541-1386. McGervey, Steve 748-0910 331-3710 218 Russell, Kathy 376-8172 748-7105 212 5tratab,-Susan 926-8675 376-8926 220 Vardaman, Steve 949-9251 376-5291 748-8364 219 Vogeler, Dawn 376-1568 205 Waters, Karla 970-420-7531 Part-time med ool Comer, Dudley 970-653-0120 970-445-7145 748-7110 Flynn, Maura 970=393-2442 Horn, Brita 653-4497 970-819-0815 748-7111 Krehbiel, Nathan 402-304-5233 Murn, Jacob 262-951-0353 Parrish, Doug 970-389-4198 Patterson, Mark 926-3308 331-2660 Peters, Hillary 476-7871 376-4853. PliSke, Kirn 97 7-L_'ii5 i Portz, Isaac 946-5863 Rohrig, Kreston, 970-274-9255 Sibley, Myles 970-331-6050 Springer, Kelsey 688-1880 Tafoya, Cip 328-5966 390-5691 Urquhart, Rebecca 390-7859 748-7130 Whalen, Matt 376-0336 754-4610 Zuckerman, Steve 331-3398 328-4365 S:\ECAD papervvork\medpool_new call list Updated: 1/21/2008 Printed: 4/30/2008 Eagle County Ambulance District Updated: 2/4/09 Ambulance -Drug Inventory Medications Quantity (Total) Adenosine 12 mg Amiodarone 300 mg Atropine 3 mg Calcium Chloride 1 g Dextrose %50 25 g Diphenhydramine 50 mg Dopamine 400 mg Epinephrine 1:10,000 3 mg Furosemide 40 mg Ipratropium 0.5 mg / 2.5 mL Albuterol 5 mg / 6 mL Lidocaine 100 mg Magnesium 2 g Naloxone 4 mg Ondansetron 8 mg Saline Bullet 9 mL Sodium Bicarbonate 100 mEq Accessories Quantity Microdrip tubing set 1 10m1 Syringes 2 5 mL Syringes 2 3 mL Syringes 2 1 mL Syringes 2 Vial access adapters 6 21g x 1.5 inch 2 10 mL NS flush 2 Isopropyl Alcohol Prep Pads 8. Printed: 5/20/2009 S:\ECAD paperwork\Drug_Lists Ambulance Updated: 1/17/09 Eagle County Ambulance District Updated: 2/2/09 Trauma Bag -Drug Inventory Medications Quantity (Total) Adenosine 12 mg Amiodarone 300 mg Aspirin (Chewable) 1 bottle Atropine 3 mg Dextrose %50 25 g Diphenhydramine 50 mg Epinephrine 1:1000 30 mg Epinephrine 1:10,000 3 mg Furosemide 60 mg Glucagon (also with dilutent) 1 mg Ipratropium 0.5 mg / 2.5 mL Albuterol 5 mg / 6 mL Lidocaine 200 mg Magnesium 2 g Naloxone 4 mg Nitroglycerin Spray 1 bottle Ondansetron 8 mg Racemic Epinephrine 0.5 ml (0.01125 g) Saline Bullet 3 mL Tetracaine 2 mL (0.5%) Accessories Quantity 10 mL Syringes 2 3 mL Syringes 2 1 mL Syringes 2 Vial access cannula 6 21 g x 1.5 inch 2 25g x 5/8 inch 2 10 mL NS flush 2 MAD ~ 1 Printed: 5/20/2009 S:\ECAD paperwork\Drug_Lists Trauma Bag Updated: 1/17/09 COUNTY APPLICATION FOR AMBULANCE VEIICLE PERMIT DATE: ~ / 12. / 2 0~ ~ NAME OF VEHICLE OWNER: Eagle County Health Service . Di atr; ct NAME OF AMBULANCE SERVICE: le C O v~ t- V ~~ 2 Gt, (~- ~C~.'~ ~l I'e e 1~ r S t C 1 C "~' ADDRESS: P • 0. Box 990 _~`"~" CFZ-y_Edwards STATE: CO ZIP: 81632 TELEPHONE NUMBER: (970} 926-5270 DESCRIPTION OF AMBULANCE: " ! 8 YEAR2~3MAKE: Ford. MODEL type): III 4 WHEEL: DRIVE(Y/I~:~ MANUFACTURERS IDENTIFICATION NUMBER (V.I.N.): ~ F D W ~ 3 5 ~ 33 i~ ~ 42 ~ $ 1 COLORADO STATE LICENSE NUMBER (REGISTRATION N0.): ~ ~ ~ S U m REGISTERED WITH THE STATE OF COLORADO AS AN EMERGENCY VEHICLE? (y/n): Y DESCRIBE COLOR SCHEME, INSIGNIA, NAME, MONOGRAM AND OTHER DISTINGUISHING CHARACTERISTIC:. Red_ yellow, and orange stripes on a white background. District logo on the front portion of the pnfient compartment ext for Stars of life on the rear doors and mirrored ~A~bulance" on h frnn DATE AMBULANCE PLACED IN SERVICE: ~ / ~ / 2~ NORMAL LOCATION OF AMBULANCE: ~ dW QC (y S INSURANCE COVERAGE ON THIS VEHICLE: A. COMPANY: See attached- Insurance Certificate B. AGENT: C. BODILY INJURY:$ / $ D: PROPERTY DAMAGE:$ / $ ~~~-~~ ~ rrrrr `~~~~~~CA L,ii~~. I I',EREBY CERTIFY , ' • T T,~ ,^3F0 ;.~fATION PRv^L'IDED iT3 iruS APPLICATION IS TRiiE T O i't~ BEST OF IvfY k~~~£15G~ k~-1~ BELIEF AND CONTAINS NO WILLFUL MI$REPRES ATIONS OR FALSIFICATION. SUBSEQUENT DETERMINA~IQtJ.'~'H~'FF~~, ,~; PERMIT FLAS BEEN ISSUED BASED ON F,. _ N CONSTITUTES GROUNDS FOR PERMIT REVOCA~It'l~I: ~ ~' ? :/3 r •~.1~ i SIGNATURE OF APPLICANT- DATE:/~/ t +~UgI,iG ~q SUBSCRIBED AN AFFIRMED BEFORE ME THIS ~ DAY OF I~_ IN THE COUNTY OF ~ ~~i,,QF COL'~~~i`~ STATE OF COLORADO . ~ -'~' r/r1~y~~ SIGNATURE OF NOTARY:v t ~ `-' IKy Commission Expires: oZ / 3 / ~d 13 (FOR OFFICE USE ONLI'} Date Received: / / Documentation V Inspection Satisfactory. (y/n): Date: / / Hold For: Recommend Approval of Permit (y/n): Comments: SIGNATURE '7 so CERTIFICATE OF MOTOR VEHICLE CONDITION DATE:;/ ~2 / b9 The undersigned, professing to be motor vehicle mechanic, has of this date, evaluated the mechanical condition o the identified ambulance and determined that this vehicle is in safe operating condition. Said evaluation does NOT warrantee future status of the ambulance due to conditions beyond my control. VEHICLE IDENTIFICATION NUMBER (v.I.N.): 11= fl w E 35 F 33 H 3 42 ~ ~°j VEI~EICLE OWNER: ~a.q I~ CoU ~ ~-y N e a I +-h ~ecv c c e, Q r's~~ ~ c ~ -- EVALUATION CHECK LIST ITEMS ACCEPTABLE NOT ACCEPTABLE COMMENTS Wheels & Tires Steering Alignment ~/ Suspension Brakes Hand Brake t~ Lights Electrical System Glass ~/ E~:haust System {~ -Fuel System Body & Sheet Metal ~ MECHANIC: // I ~ (SIGNATURE) AGEI~TCY ~ C~ ~ ,ADDRESS J4 SS ~dwa6c~5 ,'I~Q ~e blued . ~ d uxrcd eo R (632 ~~ • Public Health Division ' `4'07 Eagle County AMBULANCE INSPECTION LIST „~ 5 f c~ ~-- District: ~-~~.~ Ambulance: ~ ~ Date: ~~ Time: ( °c'~ BASIC LIFE SUPPORT I. VENTILATION EQUIPMENT a. Portable suction unit /adult & pediatric and a house (fixed system) or back-up suction unit fib. Bulb syringe r....e: Portable oxygen each with a variable flow regulator ~~ 02 bottles .house 02 G/~ d. Transparent, non-re breather fixed oxygen (vehicle) ~--- 02 mask, cannula for adult 4--02 mask, pediatric ~--'""e. Hand operated, self inflating bag-valve masks resuscitators with 02 reservoirs and standard 15mm/21 mm fittings in the following sizes: 1~~500 cc bag with en orn~d infant ` v~ e ~~,~.L,<.~ ~,G750 cc bag for chi ~' _1000 cc bag with adult mask _ vTransparent masks for infants, neonate patients, hildre and,,/a ulfs ~°- f. Nasopharyngeal airways in adult sizes 24 fr. through 32.fr g. Oropharyngeal airways in adult & pediatric sizes to include: infant, child, small adult, adult, and large adult II. PATIENT ASSESSMENT EQUIPMENT ~~ a. Blood pressure cuffs to include large adult, regular adult, child, and infant ~" b. Stethoscope L°"`c. Penlight III. SPLINTING EQUIPMENT ~ __ a. Lower extremity traction splint ~ b. Upper and lower extremity splints t-''` c. Long board, scoop, vacuum mattress or equivalent to immobilize patient head to pelvis ~'' d. Short board K.E.D. or equivalent, with the ability to immobilize the patient from head to pelvis t---'' e. Pediatric spine board or adult spine board that can be adapted to pediatric use ~''' f. Adult & pediatric head immobilization equipment L` g. Adult & pediatric cervical spine equipment immobilization equipment per medical director protocol IV. D1=iESSIIVG IVIA I Et=fIALS ~'" a. Bandages, various types & sizes ~' b. Dressings, various sizes ~ c. Sterile burn sheets _~- d. Adhesive tape ' Cagle County Ambulance Inspection List Public Health Division `4/07 V. OBSTETRICAL SUPPLIES ~'°` a. Sterile OB kit to include `~'~ towels, % 4x4 dressing, ~f`° umbilical tape or cord clamps scissors t'" bulb syringe ~'" sterile gloves ~_ thermal absorbent blanket ~'` b. Neo natal stocking cap VI. MISCELLANEOUS EQUIPMENT `~'` a. Heavy bandage scissors/shears ~" b. Two working flashlights .~_ c. Thermal absorbent blankets/blanket and appropriate heat source VII. COMMUNICATIONS EQUIPMENT :.~-- a. All communications equipment shall be maintained in good working order. The communications equipment must be capable of transmitting and receiving clear voice communications. ~b. Two-way communications that will enable the ambulance personnel to communicate with: ~..~' Dispatch _~Medical control facility or a physicians ~_Receiving facilities Mutual aid agencies VIII. EXTRICATION EQUIPMENT a. ~cp~rep~#~e-#~er-tie-~tevel-o#-extrioatt~-a0.s~is€~.~ho-age.n.cy._.provides. IX.. BODY SUBSTANCE ISOLATION (BSI) EQUIPMENT (Properly Sized To Fit All Personnel) ~~ a. Non-sterile disposable gloves, to include a minimum 1 box of latex free gloves. ~,.~' b. protective eye wear c. Non-sterile surgical masks ~ d. Safety protection gear for extrication /' e. Sharps containers for appropriate disposal and storage of medical waste and biohazards. ~ f. HEPA masks, which can be of universal size X. SAFETY EQUIPMENT Ae' a. A set of 3 warning reflectors f b. One ten pound (10 Ib.) or two five pound (5 Ib.) ABC fire extinguishers, with a minimum on one extinguisher accessible from the patient compartment and vehicle exterior. ~~ c. Child safety seat or appropriate protective restraints for patients, crew, accompanying family members or other vehicle occupants. d. Properly secured patient transport system (i.e., wheeled stretcher) ~,/ e. Triage tags 2 guy.., .. .,.y .~, „~,. ,,,~F,~„~,~„ ~~.,~ ' Public Health Division x/07 ADVANCED LIFE SUPPORT -INTERMEDIATE I. ALL EQUIPMENT LISTED IN BASIC LIFE SUPPORT-SECTION I - XII (Check) II. VENTILATION EQUIPMENT _g„~,,.~a. Adult & pediatric endotracheal intubation equipment to include stylets and an endotracheal tube stabilization device and endotracheal tubes uncuffed, ranging from 2.5-5.5, and cuffed size ranging- from 6.0-8.0 per medical director protocol. L-''b. Laryngoscope blades, straight & curved, sizes 0-4 Vic. Adult and pediatric magill forceps t-~ d. End tidal C02 detector or alternative device, approved by the FDA, for determining end tube placement III. PATIENT ASSESSMENT EQUIPMENT 1..--- a. Portable, battery operated cardiac monitor-defibrillator with strip chart recorder and adult and pediatric EKG electrodes and defibrillation capabilities ~'"' b. Pulse oximeter with adult and pediatric probes. i----c. Electronic blood glucose measuring device IV. INTRAVENOUS EQUIPMENT ~..,~ a. Adult and pediatric intravenous solutions and administration equipment per medical director protocol ~--~'b. Adult and pediatric intravenous arm boards V. PHARMACOLOGICAL AGENTS _~.,... a: Pharmacological agents and delivery devices per medical director protocol (Attach protocol) ~...--~-b. Pediatric "length based" device for sizing drug dosage calculations and sizing Equipment OTHER REGULATIONS I. DISPLAYS/IDENTIFICATION !.~° a. Each ambulance shall clearly display permanent markings on both sides showing the L name of the ambulance service under which they are licensed. b. Audible and visible warning devices and special markings are present to designate the vehicle as an ambulance II. MAINTENANCE ~T- a. At the time of application for permit, the ambulance services shall submit to the County Certificate prepared by a qi ialjfied merhanir rertlfying the ambi ilanre is in safe operating condition. ~`l~'b. Tires are safe and approved snow tires or chains are available when weather conditions demand. ° ~ `Eagle County Ambulance Inspection List Public Health Division 4/07 '" III. INSURANCE: ~IVo ambulance shall operate in the county unless it is covered by workman's compensation insurance, commercial or general liability insurance, motor vehicle liability insurance, medical malpractice and other insurance polices as required by law. Check Minimum Coverage: _Public Liability and Bodily Injury:+ Each Person $1,000,000 Each Accident (Aggregate) $2,000,000 -Property Damage: Each Accident $1,000,000 -Professional Liability: (medical malpractice) Each Person $1,000,000 Aggregate: $2,000,000 Eagle c;ountyAmbulance Inspection List Public Health Division 4/07 ,. ` Eagle County AMBULANCE INSPECTION. GENERAL INFORMATION District• ~~, Date. ~- i -z ,~ 7 V. MUTUAL AID AGREEMENT ~-'A written, contractual agreement between two licensees to supplement services in each other's response districts. VI. DESTINATION GUIDELINES .~~The Medical Director of the ambulance service shall establish destination guidelines that conform to state and regional requirements, accepted standards of medical care, or as otherwise mandated. V. STAFF Name .Address Date of Birth Training Level 4/07/07:JAH s • COUNTY APPLICATION FUR AIVIBULANCE VEHICLE PEP:MIT DATE: ~ / ~ 2../ ~ Od - i NAME OF VEHICLE OWNER Earle County Health Service_ .District NAME OF AMBULANCE SERVICE: ~e C ,o ~! v__eo, (~ 1-~ . a. 5 ~ c y ~'c e 4~ / S ~ f (C~-- ADDRESS: P • 0 • Box 9 90 CITY Edwards STATE: CO ZIP: 81632 TELEPHONE NUMBER: (970)926-5270 DESCRIPTION OF AMBULANCE: ' / YEgR~6Q`I'MAKE: Ford MODEL(type): III 4 WHEEL: DRIVE(Y/I~:~T MANUFACTURERS IDENTIFICATION NUMBER (V,LN.): I F D w~~ 5 P 15 H A i 2 0~ 3 COLORADO STATE LICENSE NUMBER (REGISTRATION N0.): O ! 6 ' ~- w x REGISTERED WITH THE STATE OF COLORADO AS AN EMERGENCY VEHICLE? (y/n): Y DESCRIBE COLOR SCHEME, INSIGNIA, NAME, MONOGRAM AND OTHER DISTINGUISHING CHARACTERISTIC: Red, yellow, and. orange stripes o.n a white background. District logo on_thefront_portion of the. ~~t~ent cgmpartment extericr_ Stars of life on the'rear doors and mirrored ~l~ihbulance" nn the frnnt_ DATE AMBULANCE PLACED INSERVICE/ ~ / ~~~ NORMAL LOCATION OF AMBULANCE: E d W 0.C d s INSURANCE COVERAGE ON THIS VEHICLE: A. COMPANY: See. attached_ Insurance Certificate B. AGENT: C. BODILY IN3URY:$ / $ D: PROPERTY DAMAGE:$ / $ I HEREBY CERTIFY THAT THE I-IVFORMA1lOiv PROVIDED IN TtilS p,PPLICATICiN iS IxuE TO THr BEST OF F BELIEF AND CONTAINS NO WILLFUL MISREPRESENTATIONS OR FALSIFICATION. SUBSEQUENT DETERM PERMIT HAS BEEN ISSUED BASED ON ON CONSTITUTES GROUNDS FOR PERMIT REVOC SIGNATURE OF APPLICANT DATE:/ ~, M ~ SUBSCRIBED AN AFFIRMED BEFORE ME THIS ~ DAY OF ~ 19~: IN THE COUNTY OF STATE OF COLORADO . a 3 1,~S1tlfll!!~~ ty~T9A~'~~v = K ~ L~~ ~-1~'• AUBLIC' ~ 4 ~~,,f~~ CoiQ~``. aoi3 a~ SIGNATURE OF NOTARY. My Commission Expires: / / (FOR OFFICE USE ONI,~ Date Received: / / Documentation V Inspection Satisfactory. (y/n): Date: / / Hold For: Recommend Approval of Permit (y/n): Comments: SIGNATURE 7~ 1 CERTIFICATE OF MOTOR VEHICLE. CONDITION DATE:/ IZ/ The undersigned, professing to be motor vehicle mechanic,-has of this date, evaluated the mechanical condition o the identified ambulance and determined that this vehicle is in safe operating condition. .Said evaluation does NOT warrantee future status of the ambulance dueto conditions beyond my control. .VEHICLE IDENTIFICATION NUMBER (V.I:N.): ~ FDw G 3 5 ~' i ~ I~ ~ 12 $13 VEHICLE OWNER: ~ag IG' ~o ~ ~n~y Nei ifh Sec y ~ c e b ~~s~f I G'}" EVALUATION CffECK LIST MECHANIC: >~ ~' I ~ (SIGNATURE) AGENCY ~C ~ ,~~ ,ADDRESS I D 55 ~ d. ~,Ua~dS \/~ I(ala~e t~lvd. f~tc;~~cd5_ co ~ 163Z ITEMS ACCEPTABLE NOT ACCEPTABLE COMMENTS Wheels & Tires Steering Alignment 1~ Suspension I~ Brakes L/ Hand Brake ~/ Lights Biectricai System Glass Exhaust System Fuel System Body & Sheet Metal ~ l~