Backup Documents 10/25/2011 Item #10AORIGINAL DOCUMENTS CHECKLIST & ROUTIulk
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 #I through #4 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 #4, complete the checklist, and forward to Sue Filson (line #5).
Route to Addressee(s)
List in routing order
Office
Initials
Date
1. Ae�.j'-
(/
appropriate.
CM 6--
Applicable)
2.
10/25/11
Agenda Item Number
10A
3.
signed by the Chairman, with the exception of most letters, must be reviewed and signed
4.
Certificate and Permit for Ambitrans
Number of Original
[m
a
57 Mitchell, Supervisor
Board of County Commissioners
I Documents Attached
1
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/prepared 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 -3740
Contact
appropriate.
Initial
Applicable)
Agenda Date Item was
10/25/11
Agenda Item Number
10A
Approved by the BCC
signed by the Chairman, with the exception of most letters, must be reviewed and signed
Type of Document
Certificate and Permit for Ambitrans
Number of Original
[m
a
Attached
COPCN
I Documents Attached
INSTRUCTIONS & CHECKLIST
I: Forms/ County Forms/ BCC Forms/ Original Documents Routing Slip W WS 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
Applicable)
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
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 BCC approval.
�Q
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 10/25/11 (enter date) and all
changes made during the meeting have been incorporated in the attached document.
The County Attorney's Office has reviewed the changes, if applicable.
I: Forms/ County Forms/ BCC Forms/ Original Documents Routing Slip W WS Original 9.03.04, Revised 1.26.05, Revised 2.24.05
!OA
MEMORANDUM
Date: January 11, 2012
To: Artie Bay, Accounting Supervisor
EMS Operations
From: Ann Jennejohn, Deputy Clerk
Minutes & Records Department
Re: Certificate of Public Convenience and Necessity for inter - facility
ambulance transport to Ambitrans Medical Transport, Inc.
Attached, please find the original document referenced above, (Item #10A)
approved by the Board of County Commissioners on October 25, 2011.
A copy of the certificate and permit will be kept on file in the Minutes and Records
Department as part of the Board's official record.
If you have any questions, please call me at 252 -8406.
Thank you.
Attachment
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10A
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: 16 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 day of 0t U 6&11--- '2011
ATTEST: ; • ° a y �, o�� BOARD OF COUNTY COMMISSIONERS
DWIG .13�& ,��LERK COLLIER COUNTY, FLORIDA
Clef, Fred W. Coyle, Chairman \
Approved as to orm and legal sufficiency:
Assistant County Attorney
Item # 16L
Agenda M" `J1 1
Date
'we
Redd
AMBITRANS MEDICAL TRANSPORT, INC.
LICENSE NUMBER: ALS804
10/25/2011 Item 10.A.
ATTACHMENT "A"
Name
Profession
License
Effective Date
1FDSS34P35HA65845
Vehicle
Permit (ALS)
13135
1/1/1901
1FDSS34PX5HA65843
Vehicle
Permit (ALS)
13137
1/1/1901
1FDSS34P16HB19659
Vehicle
Permit (ALS)
13644
3/23/2006
1FDSS34PX6DB13172
Vehicle
Permit (ALS)
13952
11/7/2006
1FDSS34P78DA64922
Vehicle
Permit (ALS)
14787
3/17/2008
1FDXE45F23HB15317
Vehicle
Permit (ALS)
15452
4/2/2009
1FDSS34P09DA59420
Vehicle
Permit (ALS)
15579
6/26/2009
1FDSS3ES4ADA31207
Vehicle
Permit (ALS)
15922
2/15/2010
1FDSS3ES6ADA31208
Vehicle
Permit (ALS)
15923
2/15/2010
1FDSS3ES4BDA26137
Vehicle
Permit (ALS)
16462
2/24/2011
1FDSS3ES6BDA26138
Vehicle
Permit (ALS)
16463
2/24/2011
1G89G5B68A1114023
Vehicle
Permit (ALS)
16555
4/4/2011
1GB9G5B62A1113871
Vehicle
Permit (ALS)
16
4/4/2011
1FDSS34F74HB77334
Vehicle
Permits (BLS)
3926
12/7/2005
1FDSS34PX6HB19658
Vehicle
Permits (BLS)
3948
3/23/2006
1FDSS34P96DB41853
Vehicle
Permits (BLS)
4039
3/28/2007
1FDWE35F92HA44797
Vehicle
Permits (BLS)
413
12/19/2007
1FDSS34P15HA65844
Vehicle
Permits (BLS)
4142
2/21/2008
1FDWE35F8YHA94731
Vehicle
Permits (BLS)
4177
7/17/2008
1FDXE45F2YHB54092
Vehicle
Permits (BLS)
4228
4/2/2009
1FDSS3ESSADA25626
Vehicle
Permits (BLS)
4279
2/15/2010
1FDSS34F03HA74295
Vehicle
Permits (BLS)
4310
7/12/2010
1FDSS3ES3BDA26145
Vehicle
Permits (BLS)
4355
2/24/2011
Packet Page -358-
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