Backup Documents 09/26/2017 Item #16E10 ORIGINAL DOCUMENTS CHECKLIST & ROUTING SLIP
TO ACCOMPANY ALL ORIGINAL DOCUMENTS SENT TO 16 E 0
THE BOARD OF COUNTY COMMISSIONERS OFFICE FOR SIGNA
Print on pink paper. attach to oi ig mi tiucument. I he completed routing slip and original documents arc to he lornarded to the Count) Attorney Office
at the time the item is placed on the agenda. All completed routing slips and original documents must be received in the County Attorney Office no later
than Monday preceding the Board meeting.
**NEW** ROUTING SLIP
Complete routing lines#1 through#2 as appropriate for additional signatures,dates,and/or information needed. If the document is already complete with the
exception of the Chairman's signature,draw a line through routing lines#1 through#2,complete the checklist,and forward to the County Attorney Office.
Route to Addressee(s) (List in routing order) Office Initials Date
1.
2.
3. County Attorney Office County Attorney Office q Ia 5p7
4. BCC Office Board of County
Commissioners WAS/ -��--,
5. Minutes and Records Clerk of Court's Office
PRIMARY CONTACT INFORMATION
Normally the primary contact is the person who created/prepared the Executive Summary. Primary contact information is needed in the event one of the
addressees above,may need to contact staff for additional or missing information.
Name of Primary Staff Kathy Heinrichsberg Phone Number 252-3622
Contact/ Department
Agenda Date Item was September/172 Agenda Item Number 16E I 0
Approved by the BCC 7 t, p'•1,
Type of Document Executive Sumthary,Permit,"VIN list,and Number of Original 2
Attached Permit. fA' r b..rcs Documents Attached
PO number or account
number if document is
to be recorded
INSTRUCTIONS & CHECKLIST
Initial the Yes column or mark`tel/A"in the Not Applicable column,whichever is Yes N/A(Not
appropriate. (Initial) Applicable)
1. Does the document require the chairman's original signature? S.‘1(4,,......19 Ori
2. Does the document need to be sent to another agency for additional signatures? If yes, KH
provide the Contact Information(Name;Agency;Address;Phone)on an attached sheet.
3. Original document has been signed/initialed for legal sufficiency. (All documents to be
signed by the Chairman,with the exception of most letters,must be reviewed and signed KH
by the Office of the County Attorney.
4. All handwritten strike-through and revisions have been initialed by the County Attorney's KH
Office and all other parties except the BCC Chairman and the Clerk to the Board
5. The Chairman's signature line date has been entered as the date of BCC approval of the KH
document or the final negotiated contract date whichever is applicable.
6. "Sign here"tabs are placed on the appropriate pages indicating where the Chairman's ,
signature and initials are required. `��`�
7. In most cases(some contracts are an exception),the original document and this routing slip KB
should be provided to the County Attorney Office at the time the item is input into SIRE.
Some documents are time sensitive and require forwarding to Tallahassee within a certain
time frame or the BCC's actions are nullified. Be a e of your deadlines!
8. The document was approved by the BCC on Sept ice,2017 and all changes made KH N/A is not
during the meeting have been incorporated in the attached document. The County an option for
Attorney's Office has reviewed the changes,if applicable. this line.
9. Initials of attorney verifying that the attached document is the version approved by the ' N/A is not
BCC,all changes directed by the BCC have been made,and the document is ready for the an option for
Chairman's signature. this line.
PLEASE RETURN ALL DOCUMENTS TO KATHY HEINRICHSBERG E ERG. MNGMNT
I:Forms/County Forms/BCC Forms/Original Documents Routing Slip WWS Original 9.03.04,Revised 1.26.05,Revised 2.24.05:Revised 11/30/12
1 6E 1 0
MEMORANDUM
Date: September 29, 2017
To: Kathy Heinrichsberg, Executive Secretary
Bureau of Emergency Services
From: Ann Jennejohn, Deputy Clerk
Minutes & Records Department
Re: Annual COPCN for Ambitrans Medical Transport, Inc. to
provide Class 2 Advanced Life Support (ALS) inter-facility
transport ambulance service for a 1- year period
Attached, please find the original document referenced above, (Item #16E10)
approved by the Board of County Commissioners on September 26, 2017.
A copy of the document will be held in the Minutes and Records Department for
the Board's Official Record.
If you have any questions, please feel free to call me at 252-8406.
Thank you
Attachment
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16E10 •
COLLIER COUNTY FLORIDA
Renewal of Class "2" COPCN
Name of Service: Ambitrans Medical Transport, Inc.
Name of Owner: Michael and Lorraine Grant
Principle Address of Service: 4351 Pinnacle Street, Charlotte Harbor, FL 33980
Business Telephone: (941) 743-3665
Description of Service: Inter-facility and out-of-county transport for Collier County
Number of Ambulances: (37)Thirty-seven
See attachment "A" for description of vehicles.
This permit, as provided by Ordinance No. 2004-12,as amended, shall allow the above
named Ambulance Service to operate inter-facility and out of county transports for a fee
or charge for the following area(s): Collier County for one year from the date executed
hereon, except that this permit may be revoked by the Board of County Commissioners
of Collier County at any time the service named herein shall fail to comply with any
local, state or federal laws or regulation application to the provisions of Emergency
Medical Services.
f 4,11
Issued and approved this o2Cp day of ,2017
ATTEST: BOA',J • OUNTY COMMISSIONERS
DWIGHT E. BROCK, CLERK COLS ' J LINTY, FLORI P •
• • a • /&det(Awf Air
, erk Penny TayloA' airman ,
Attest as to Ch
signature only.
Approved as to form and legality:
Jen -r A. Belpe \\
m
Assistant County A-orney a�
0.
i�9,
Ambitrans Medical Transport, Inc.
16E 10
Licensed Ambulances 2017
VIN Type License No. Date
1FDSS3ESODDA41561 VEHICLE PERMITS(BLS) 4956 2/18/2016
1FDSS3ES1BD827801 VEHICLE PERMIT(ALS) 17027 12/8/2011
•1FDSS3ES3BDA26145 VEHICLE PERMITS(815) 4255 2/24/2011
1FDSS3ES3CDA18371 VEHICLE PERMITS(BLS) 4$32 4/8/2015
1FDSS3ES4BDA26137 VEHICLE PERMITS(BLS) 4775 7/31/2014
1FDSS3ESSADA25626 VEHICLE PERMITS(BLS) 4677 8/1/2013
1FDSS3ESSCDA18372 VEHICLE PERMITS(BLS) 454 2/18/2016
1FDSS3ES6ADA31208 VEHICLE PERMITS(BLS) 4678 8/1/2013
1FDSS3ES6BDA26138 VEHICLE PERMITS(BLS) 44Th 3/29/2012
1FDSS3ES6BDB36820 VEHICLE PERMITS(BLS) 4955 2/18/2016
1FDSS3ES7BDB27799 VEHICLE PERMITS(BLS) 4777 7/31/2014
1FDSS3ES7BDB27804 VEHICLE PERMIT(ALS) 17026 12/8/2011
1FDSS3ES7DDB06017 VEHICLE PERMIT(AU) 18017 7/23/2013
1FDSS3ES8DDB02266 VEHICLE PERMITS(BLS) 4776 7/31/2014
1FDSS3ES9EDA22265 VEHICLE PERMITS(BLS) 4a} 3/10/2015
1FDWE35F92HA44797 VEHICLE PERMITS(BLS) 4133 12/19/2007
1FDWE3FD7ADA20886 VEHICLE PERMITS(BLS) 5121 3/8/2017
1FDWE3FS1ADA32547 VEHICLE PERMIT(ALS) 18534 7/31/2014
1FDWE3FS3ADA32551 VEHICLE PERMITS(BLS) 4822 3/10/2015
1FDWE3FS4ADA62447 VEHICLE PERMITS(BLS) 5119 3/8/2017
1FDWE3FS5ADA20885 VEHICLE PERMITS(BLS) 5120 3/8/2017
1FDWE3FS5ADA69150 VEHICLE PERMIT(ALS) 18536 7/31/2014
1FDWE3FS6BDA01957 VEHICLE PERMIT(ALS) 20496 3/8/2017
1FDWE3FS68DA87027 VEHICLE PERMITS(BLS) 4821 3/10/2015
1FDWE3FS7ADA69148 VEHICLE PERMIT(ALS) 18535 7/31/2014
1FDWE3FS7BDA91166 VEHICLE PERMIT(AU) 18895 3/10/2015
1FDWE3FS8BDA09607 VEHICLE PERMIT(AU) 18896 3/10/2015
1FDWE3FS9ADA34661 VEHICLE PERMIT(ALS) 19943 6/6/2016
1FDWE3FSXADA32546 VEHICLE PERMITS(BLS) 5037 8/25/2016
1FDWR3FSXBDA09608 VEHICLE PERMIT(ALS) 19338 8/24/2015
iFDXE4FS2BDB29932 VEHICLE PERMIT(ALS) 19699 1/19/2016
1FDXE4FS3BDB29941 VEHICLE PERMIT(ALS) 19758 2/18/2016
1FDXE4FS3BDB35786 VEHICLE PERMIT(ALS) 19759 2/18/2016
1FDXE4F54BDB35781 VEHICLE PERMIT(ALS) 19757 2/18/2016
1FDXE4FS6CDA90604 VEHICLE PERMIT(ALS) 19956 6/20/2016
-"VEHICLE VEHICLE PERMIT(ALS) 19957 6/20/2016
1FDXE4FS9EDA75257 VEHICLE PERMIT(ALS) 18361 5/6/2014
EXHIBIT
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