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Backup Documents 03/22/2011 Item #16F2ORIGINAL DOCUMENTS CHECKLIST & ROUTING SLIP 16 F 2 TO ACCOMPANY ALL ORIGINAL DOCUMENTS SENT TO THE BOARD OF COUNTY COMMISSIONERS OFFICE FOR SIGNATURE Print on pink paper. Attach to original document. Original documents should be hand delivered to the Board Office. The completed routing slip and original documents are to be forwarded to the Board Office only after the Board has taken action on the item.) ROUTING SLIP Complete routing lines # 1 through #4 as appropriate for additional signatures, dates, and/or information needed. If the document is already complete with the exeemi.. of the Chairman's %umamre _ draw a line through routine lines #1 throueh #4. complete the checklist, and forward to Sue Filson (line 45). Route to Addressee(s) List in routing order Office Initials Date I. appropriate. Initial Applic able 2. 3/22/11 Agenda Item Number 16F c2 3. signed by the Chairman, with the exception of most letters, must be reviewed and signed 4. Certificate of COPCN and Permit Number of Original 2 — M &R — Please 5. Ian Mitchell, Supervisor Board of County Commissioners Documents Attached 3 6. Minutes and Records Clerk of Court's Office PRIMARY CONTACT INFORMATION (The primary contact is the holder of the original document pending BCC approval. Normally the primary contact is the person who created/preparcd the executive summary. Primary contact information is needed in the event one of the addressees above, including Sue Filson, need to contact staff for additional or missing information. All original documents needing the BCC Chairman's signature are to be delivered to the BCC office only after the BCC has acted to approve the item. Name of Primary Staff Artie Bay Phone Number 252 -3746 Contact appropriate. Initial Applic able Agenda Date Item was 3/22/11 Agenda Item Number 16F c2 Approved by the BCC signed by the Chairman, with the exception of most letters, must be reviewed and signed Type of Document Certificate of COPCN and Permit Number of Original 2 — M &R — Please Attached resolutions, etc. signed by the County Attorney's Office and signature pages from Documents Attached return originals INSTRUCTIONS & CHECKLIST 1: Forms/ County Forms/ BCC Forms / Original Documents Routing Slip WINS Original 9.03.04, Revised 1.26.05, Revised 2.24.05 Initial the Yes column or mark "N /A" in the Not Applicable column, whichever is Yes N/A (Not appropriate. Initial Applic able 1. 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 by the Office of the County Attorney. This includes signature pages from ordinances, resolutions, etc. signed by the County Attorney's Office and signature pages from contracts, agreements, etc. that have been fully executed by all parties except the BCC Chairman and Clerk to the Board and possibly State Officials. 2. All handwritten strike- through and revisions have been initialed by the County Attorney's Office and all other parties except the BCC Chairman and the Clerk to the Board Gn 3. 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. 4. "Sign here" tabs are placed on the appropriate pages indicating where the Chairman's signature and initials are required. 5. In most cases (some contracts are an exception), the original document and this routing slip should be provided to Sue Filson in the BCC office within 24 hours of 13CC approval. Some documents are time sensitive and require forwarding to Tallahassee within a certain time frame or the BCC's actions are nullified. Be aware of your deadlines! 6. The document was approved by the BCC on enter date) and all changes made during the meeting have been incorporat d in the attached document. The County Attorney's Office has reviewed the changes, if applicable. 1: Forms/ County Forms/ BCC Forms / Original Documents Routing Slip WINS Original 9.03.04, Revised 1.26.05, Revised 2.24.05 16F2 —1*0011�Ul Date: March 23, 2011 To: Artie Bay EMS, Operations Analyst From: Teresa Polaski, Deputy Clerk Minutes & Records Department Re: EMS Grant Application & Resolution 2011 -33 Attached please find one (1) original Certificate and one (1) certified copy of the Permit referenced above, (Agenda Item #16F2) approved by the Collier County Board of County Commissioners on Tuesday, March 22, 2011. The Minutes and Records Department has retained the original permit to be kept in the Board's Official Records. If you have any questions, please call me at 252-8411. Thank you. 16F2 COLLIER COUNTY FLORIDA Renewal of Class "B" COPCN Name of Service: NCH Ambulance Services Name of Owner: NCH Healthcare System Principle Address of Service: 2157 Pine Ridge Road, Naples, Florida Business Telephone: (239) 513 -7080 Description of Service: Post hospital intrafacility transports and out of County transport for the NCH Healthcare System Number of Ambulances: 3 Ground Units; NCH will operate no less than one (l) and up to three (3) Ground Units on immediate call at all times. See attachment for description of vehicles. This permit, as provided by Ordinance No. 2004 -12, as amended shall allow the above named Ambulance Service to operate post hospital intrafacility transports between its facilities and out of County transports for a fee or charge for the following area(s): Collier County until the expiration date 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 Chapter 401, Florida Statutes, and any local, state or federal laws or regulation application to the provisions of Emergency Medical Services. Within forty -five (45) days of approval of the renewal, NCH Healthcare System must staff a transport unit for all days and hours of operation for the Marco Island Urgent Care Center location. Collier County EMS will not be required to supplement NCH Healthcare System transports. Issued and approved this C:P dday of CC,k 2011. ATTESTt! BOARD OF COUNTY COMMISSIONERS DYY T E. , B C, CLERK COLLIER COUNTY, FLORIDA ,At st aaT tol Fred W. Coyle, Chairman Approyed.as*td form and legal sufficiency: Jennifer B. White Assistant County Attorney 16F 2 t 3 � Jutras, Nam From: Hernandez, Jose Sent; Monday, November 16, 2010 3:65 PM 7o: Jutras, Nanoy Co: Kollnski, Juanita SubJeot: RE: NCH Ambulances Nancy, Hure is the informalfon you have requostod; AMnUtANCL'11Crusader VIN111FDS534P8GOA54283 AMNUTANCIE 1:011D 1097 E 350 VIN1111 °UKODf5KHA3J' /11 Jose H.Flornandez Flxod Asaeta & rrojeots Accountant NCH Hoailhoaro 5ystom Naples, FL. USA P. 230 613 7016 JQse2 .byL8UlklS&C4�nJJn)SIA4.rft Maio do1rtplial 11A mall uIllm you 1111181 Prom: Kollnski, Juanita Sent; Monday, November 15, 2010 327 PM To: Hernandez, Jose Cc: Jutras, Nancy Subject: FW: NCH Ambulances Jose, Can you please check fixed assets to see what we have? Juanita Kollnski Accounting Manager NCI-1 Healthcare System, Inc. (239)513.7602 From; Jutras, Nancy Santi Monday, November 15, 2010 2:43 PM To: Kollnski, Juanita Subject: NCH Ambulances I'll''unnita - x am helping Kelly with the Renewal of Certificate of Public Convenience and Necessity with the Cowtty. One question It is asking is the number and a brief deser IP4lon of the antbulancas. Qo you have that Info? Thanke for your helpi e�Cl/)ZP�e.l "�/Mlll1 Executive Assistant to the, { \ } \ § k ]) \ E ] f z f \ \ 3 t ) { } k k _ \ ; \ \ \ \ k ) V) k < f � [ { ] ) |) 0 {) t \ () ' f f \ \ ZE()\kCn � 4 , = © = © u k y §< )f ` J§% ■ (§u § )� \ � §` } ( � } } k k §< )f ` J§% ■ (§u § )� \ � §` } ( � �2 �§ 7 \ � \ �2