Backup Documents 09/10/2013 Item #16E16 ORIGINAL DOCUMENTS CHECKLIST & ROUTING SLIPi
TO ACCOMPANY ALL ORIGINAL DOCUMENTS SENT TO 1 6 E 1 6
THE BOARD OF COUNTY COMMISSIONERS OFFICE FOR SIGNATURE
Print on pink paper. Attach to original document. The completed routing slip and original documents are to be forwarded to the County 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 �� fix,O\'N3
'Ttvvoi-Peti' Pc-lied it
4. BCC Office Board of County
Commissioners
5. Minutes and Records Clerk of Court's Office
Ci h 1 I (3 G:oSR,
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 Christine Boni 'E1-,, -��.c Phone Number 252-3617
Contact/ Department / 5c,,rv. s /
Agenda Date Item was 9/10/13 i Agenda Item Number 16E16 1/
Approved by the BCC
Type of Document Permit and Certificate Number of Original 1 each
Attached Documents Attached
PO number or account Need originals to send
number if document is 14F°2 m to Ambitrans
to be recorded �xr .ko cZ tV 7 .
INSTRUCTIONS& CHECKLIST
Initial the Yes column or mark"N/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? C ✓
2. Does the document need to be sent to another agency for additional signatures? If yes, 1216 vVe
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 C b
by the Office of the County Attorney.
4. All handwritten strike-through and revisions have been initialed by the County Attorney's N IA
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
document or the final negotiated contract date whichever is applicable. et5
6. "Sign here"tabs are placed on the appropriate pages indicating where the Chairman's C(>) ✓
signature and initials are required.
7. In most cases(some contracts are an exception),the original document and this routing slip
should be provided to the County Attorney Office at the time the item is input into SIRE. ( V
Some documents are time sensitive and require forward' g to Tallahassee within a certain
time frame or the BCC's actions are nullified. Be aw a of your deadlines!
8. The document was approved by the BCC on qI IC 1I')(enter date)and all changes made �
during the meeting have been incorporated in the attached document. The County 9,5
Attorney's Office has reviewed the changes,if applicable.
9. Initials of attorney verifying that the attached document is the version approved by the
BCC,all changes directed by the BCC have been made,and the document is ready for the .zz,r,
Chairman's signature.
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
16E16
MEMORANDUM
Date: September 17, 2013
To: Christine Boni, Accountant
Bureau of Emergency Services
From: Martha Vergara, Deputy Clerk
Minutes & Records Department
Re: Permit & Certificate
Attached for your records is the original Permit & Certificate as referenced above,
(Agenda Item #16E16) adopted by the Board of County Commissioners on Tuesday,
September 10, 2013.
If you have any questions, please call me at 252-7240.
Thank you.
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16E16
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: Intrafacility and out of county transport for Collier County
Number of Ambulances: 20 Ground Units available.
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 intrafacility 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.
Issued and approved this 10th day of September, 2013.
^eon
1 ' ST:' ` • BOA'0 I1 F C• Y COMMISSIONERS
DWIGHT E. BROcK, CLERK CO IE' •O , FLORIDA
1
o' I / ,tom; , iA
Att tfas.to Chairmen s Ae•u erk Geor_.is Air filler, Esq., Chairwoman
signature only. J.
Approved as to form and legality:
Je fer A. Belpedi4
Assistant County Attorney
16E16
ATTACHMENT "A"
Ambitrans Medical Transport
Vehicle Listing
1FDXE45F23HB15317 Vehicle Permit (ALS) 15452
1FDSS3ES4BDA26137 Vehicle Permit (ALS) 16462
1FDSS3ES7BDB27799 Vehicle Permit (ALS) 17025
1FDSS3ES7BDB27804 Vehicle Permit (ALS) 17026
1FDSS3ES1BDB27801 Vehicle Permit (ALS) 17027
1FDSS3ES3CDA18371 Vehicle Permit (ALS) 17149
1FDSS3ES5CDA18372 Vehicle Permit (ALS) 17150
1FDSS3ES6BDB36820 Vehicle Permit (ALS) 17356
1FDSS3ES4DDB02264 Vehicle Permit (ALS) 18015
1FDSS3ES8DDB02266 Vehicle Permit (ALS) 18016
1FDSS3ES7DDB06017 Vehicle Permit (ALS) 18017
1FDWE35F92HA44797 Vehicle Permits (BLS) 4133
1FDXE45F2YHB54092 Vehicle Permits (BLS) 4228
1FDSS3ES3BDA26145 Vehicle Permits (BLS) 4355
1FDXE45F73HB48975 Vehicle Permits (BLS) 4470
1FDSS3ES6BDA26138 Vehicle Permits (BLS) 4475
1FDSS34P78DA64922 Vehicle Permits (BLS) 4476
1FDSS34P09DA59420 Vehicle Permits (BLS) 4615
1FDSS3ES5ADA25626 Vehicle Permits (BLS) 4677
1FDSS3ES6ADA31208 Vehicle Permits (BLS) 4678
As of August 14, 2013
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