Backup Documents 10/09/2018 Item #16E 1 ORIGINAL DOCUMENTS CHECKLIST & ROUTING SLIP L E
TO ACCOMPANY ALL ORIGINAL DOCUMENTS SENT TO (�
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 JAB 10/9/18
10-
4. BCC Office Board of County "oC
Commissioners ��r3 161G-1g
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 Dan Summers Bureau of Emergency 239-252-3601 tev
Contact/Department Services
Agenda Date Item was 10/9/18 Agenda Item Number 16E1
Approved by the BCC
Type of Document Ambitrans Certificate and Renewal Number of Original 1
Attached Documents Attached
PO number or account n/a
number if document is
to be recorded
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 signa e STAMP OK
2. Does the document need to be sent to another agency for ads itiona signatures? If yes, NA
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 JAB
signed by the Chairman,with the exception of most letters,must be reviewed and signed
by the Office of the County Attorney.
4. All handwritten strike-through and revisions have been initialed by the County Attorney's NA
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 JAB
document or the fmal negotiated contract date whichever is applicable.
6. "Sign here"tabs are placed on the appropriate pages indicating where the Chairman's JAB
signature and initials are required.
7. In most cases(some contracts are an exception),the original document and this routing slip NA
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 aware of your deadlines!
8. The document was approved by the BCC on 10/9/18 and all changes made during the JAB
meeting have been incorporated in the attached document. The County 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, 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
1 6 E I
MEMORANDUM
Date: October 16, 2018
To: Kathy Heinrichsberg, Executive Secretary
Bureau of Emergency Services
From: Martha Vergara, Sr. Deputy Clerk
Minutes & Records Department
Re: COPCN & Permit
Ambitrans Medical Transport, Inc.
Attached are one (1) original document as referenced above, (Item #16E1) as
approved by the Board of County Commissioners on Tuesday, October 9, 2018.
The Board's Minutes & Records Department has kept the original as part of the
Board's Official Records.
If you have any questions, please contact me at 252-7240.
Thank you.
Attachment
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, 1 6 E 1
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: (73) Seventy-three
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 beginning on October 24,
2018, 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 1�� day of (_J , 2018
ATTEST: • ` BOARD OF C TY COMMI IONERS
CRYSTAL K. KINZ•EL COLLIER , FLO' • ,
CLERK f.
\031,- •
•
@St as t4 Coal • ty er — Andy Solis, Chairman
signature only.
Approved as to form and legality:
Jen4r A. Belped , o�,
Assistant County Attorney e •
-.r
' i 1 ' ' A 1 6 E 1
EXHIBIT
Page___1.—....of.a...........
Ambitrans Medical Transport, Inc.
Name Relationship Profession License Effective Date
1FDSS3ESODDA41561 PERMIT VEHICLE PERMIT(ALS) 20888 8/24/2017
1FDSS3ES0DDA41561 PERMIT VEHICLE PERMITS(BLS) 4956 2/18/2016
1FDS53E51BDB27801 PERMIT VEHICLE PERMIT(ALS) 17027 12/8/2011
1FDSS3ES1BDB27801 PERMIT VEHICLE PERMITS(BLS) 5212 8/24/2017
1FDSS3ES3BDA26145 PERMIT VEHICLE PERMIT(ALS) 20881 8/24/2017
1FDSS3ES3BDA26145 PERMIT VEHICLE PERMITS(BLS) 4355 2/24/2011
1FDSS3ES3CDA18371 PERMIT VEHICLE PERMIT(ALS) 20885 8/24/2017
1FDS53ES3CDA18371 PERMIT VEHICLE PERMITS(BLS) 4832 4/8/2015
1FD553ES4BDA26137 PERMIT VEHICLE PERMIT(ALS) 20882 8/24/2017
1FDSS3ES4BDA26137 PERMIT VEHICLE PERMITS(BLS) 4775 7/31/2014
1FDSS3ES5ADA25626 PERMIT VEHICLE PERMIT(ALS) 20879 8/24/2017
1F DSS3ESSADA25626 PERMIT VEHICLE PERMITS(BLS) 4677 8/1/2013
1FDS53ES5CDA18372 PERMIT VEHICLE PERMIT(ALS) 20886 8/24/2017
1FDSS3ESSCDA18372 PERMIT VEHICLE PERMITS(BLS) 4954 2/18/2016
1FDSS3ES6ADA312O8 PERMIT VEHICLE PERMIT(ALS) 20880 8/24/2017
1FDSS3ES6ADA31208 PERMIT VEHICLE PERMITS(BLS) 4678 8/1/2013
1FDSS3ES6BDA26138 PERMIT VEHICLE PERMIT(ALS) 20884 8/24/2017
1FDSS3ES6BDA26138 PERMIT VEHICLE PERMITS(BLS) 4475 3/29/2012
1FD553ES68D836820 PERMIT VEHICLE PERMIT(ALS) 20887 8/24/2017
1FDSS3ES6BDB36820 PERMIT VEHICLE PERMITS(BLS) 4955 2/18/2016
1FDSS3ES7BDB27799 PERMIT VEHICLE PERMIT(ALS) 20883 8/24/2017
1FDS53ES7BDB27799 PERMIT VEHICLE PERMITS(BLS) 4777 7/31/2014
1FDSS3ES7BDB27804 PERMIT VEHICLE PERMIT(ALS) 17026 12/8/2011
1FDSS3ES7BDB27804 PERMIT VEHICLE PERMITS(BLS) 5213 8/24/2017
1FDSS3ES7DDB06017 PERMIT VEHICLE PERMIT(ALS) 20928 8/31/2017
1FDSS3ES7DDB06017 PERMIT VEHICLE PERMITS(BLS) 5214 8/24/2017
1FDSS3ES8DDB02266 PERMIT VEHICLE PERMIT(ALS) 20889 8/24/2017
1FDSS3ES8DDB02266 PERMIT VEHICLE PERMITS(BLS) 4776 7/31/2014
1FDS53ES9EDA22265 PERMIT VEHICLE PERMIT(ALS) 20890 8/24/2017
1FDSS3E59EDA22265 PERMIT VEHICLE PERMITS(BLS) 4823 3/10/2015
1FDWE35F92HA44797 PERMIT VEHICLE PERMITS(BLS) 4133 12/19/2007
1FDWE3FD7ADA20886 PERMIT VEHICLE PERMITS(BLS) 5121 3/8/2017
1FDWE3FS1ADA32547 PERMIT VEHICLE PERMIT(ALS) 18534 7/31/2014
1FDWE3FS3ADA32551 PERMIT VEHICLE PERMIT(ALS) 20895 8/24/2017
1FDWE3FS3ADA32551 PERMIT VEHICLE PERMITS(BLS) 4822 3/10/2015
1FDWE3FS4ADA62447 PERMIT VEHICLE PERMIT(ALS) 20891 8/24/2017
1FDWE3FS4ADA62447 PERMIT VEHICLE PERMITS(BLS) 5119 3/8/2017
1FDWE3F55ADA20885 PERMIT VEHICLE PERMIT(ALS) 20892 8/24/2017
1FDWE3FS5ADA20885 PERMIT VEHICLE PERMITS(BLS) 5120 3/8/2017
1FDWE3FSSADA69150 PERMIT VEHICLE PERMIT(ALS) 18536 7/31/2014
1FDWE3FS6BDA01957 PERMIT VEHICLE PERMIT(ALS) 20496 3/8/2017
1FDWE3FS6BDA01957 PERMIT VEHICLE PERMITS(BLS) 5211 8/24/2017
1FDWE3F56BDA87027 PERMIT VEHICLE PERMIT(ALS) 20896 8/24/2017
1FDWE3FS6BDA87027 PERMIT VEHICLE PERMITS(BLS) 4821 3/10/2015
1FDWE3FS7ADA20886 PERMIT VEHICLE PERMIT(ALS) 20893 8/24/2017
1FDWE3FS7ADA69148 PERMIT VEHICLE PERMIT(ALS) 18535 7/31/2014
EXHIBIT ......b..____ .
Page I o1 —
6
1ÔE E 1
Ambitrans Medical Transport, Inc.
1FDWE3FS7ADA69148 PERMIT VEHICLE PERMITS(BLS) 5216 8/24/2017
1FDWE3FS7BDA91166 PERMIT VEHICLE PERMIT(ALS) 18895 3/10/2015
1FDWE3FS7BDA91166 PERMIT VEHICLE PERMITS(BLS) 5217 8/24/2017
1FDWE3FS88DA01958 PERMIT VEHICLE PERMIT(ALS) 21048 10/25/2017
1FDWE3FS88DA01958 PERMIT VEHICLE PERMITS(BLS) 5368 10/25/2017
1FDWE3FS8BDA09607 PERMIT VEHICLE PERMIT(ALS) 18896 3/10/2015
1FDWE3FS8BDA09607 PERMIT VEHICLE PERMITS(BLS) 5218 8/24/2017
1FDWE3FS9ADA34661 PERMIT VEHICLE PERMIT(ALS) 19943 6/6/2016
1FDWE3FS9ADA34661 PERMIT VEHICLE PERMITS(BLS) 5224 8/24/2017
1FDWE3FSXADA32546 PERMIT VEHICLE PERMIT(ALS) 20894 8/24/2017
1FDWE3FSXADA32546 PERMIT VEHICLE PERMITS(BLS) 5037 8/25/2016
1FDWEFS1ADA32547 PERMIT VEHICLE PERMITS(BLS) 5215 8/24/2017
1FDWR3FSXBDA09608 PERMIT VEHICLE PERMIT(ALS) 19338 8/24/2015
1FDWR3FSXBDA09608 PERMIT VEHICLE PERMITS(BLS) 5219 8/24/2017
1FDXE4FS2BDB29932 PERMIT VEHICLE PERMIT(AU) 19699 1/19/2016
1FDXE4FS2BDB29932 PERMIT VEHICLE PERMITS(BLS) 5220 8/24/2017
1FDXE4FS3BDB29941 PERMIT VEHICLE PERMIT(ALS) 19758 2/18/2016
1FDXE4FS3BDB29941 PERMIT VEHICLE PERMITS(BLS) 5222 8/24/2017
1FDXE4F53BDB35786 PERMIT VEHICLE PERMIT(ALS) 19759 2/18/2016
1FDXE4FS3BDB35786 PERMIT VEHICLE PERMITS(BLS) 5223 8/24/2017
1FDXE4F548D635781 PERMIT VEHICLE PERMIT(ALS) 19757 2/18/2016
1FDXE4FS4BDB35781 PERMIT VEHICLE PERMITS(BLS) 5221 8/24/2017
1FDXE4FS6CDA90604 PERMIT VEHICLE PERMIT(ALS) 19956 6/20/2016
1FDXE4FS6CDA90604 PERMIT VEHICLE PERMITS(BLS) 5225 8/24/2017
1FDXE4FS8BDB35783 PERMIT VEHICLE PERMIT(ALS) 19957 6/20/2016
1FDXE4FS8BDB35783 PERMIT VEHICLE PERMITS(BLS) 5226 8/24/2017
1FDXE4FS9EDA75257 PERMIT VEHICLE PERMIT(ALS) 18361 5/6/2014
0