Backup Documents 09/22/2015 Item #16E 9 ORIGINAL DOCUMENTS CHECKLIST & ROUTING SLIP
TO ACCOMPANY ALL ORIGINAL DOCUMENTS SENT TO oR6 E 9 .
THE BOARD OF COUNTY COMMISSIONERS OFFICE FOR SIGNAT
Print on pink paper. Attach to original document. The completed routing slip and original documents are to be forwarded to the ounty 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 ' t-CAA�Q 7
4. BCC Office Board of County
Commissioners V14 S °1VZ2k1C;
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 informatio .
Name of Primary Staff Phone Number 252-3622
Contact/ Department Kathy Heinrichsberg,Ex cutive Secretary
Agenda Date Item was September 22,2015 Agenda Item Number
Approved by the BCC 16E9 16/ 1
Type of Document COCPN Permit and Certificate Number of Original 2- 1 Permit
Attached Documents Attached 1 Certificate
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 signature? S-t+r," e ,( KH
2. Does the document need to be sent to another agency for additional signa es? If yes, N/A
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
by the Office of the County Attorney.
4. All handwritten strike-through and revisions have been initialed by the County Attorney's ylk 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 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 KH
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. 21A
Some documents are time sensitive and require f rwarding to Tallahassee within a certain
time frame or the BCC's actions are nullified. a aware of your deadlines!
8. The document was approved by the BCC o r and all changes KH N/A is not
made during the meeting have been incorporated in the attached document. The :I option for
County Attorney's Office has reviewed the changes,if applicable. thi line.
9. Initials of attorney verifying that the attached document is the version approved by the N/' is not
BCC,all changes directed by the BCC have been made,and the document is ready for th: 0 a- option for
Chairman's signature. his line.
I:Forms/County Forms/BCC Forms/Original Documents Routing Slip WWS Original 9.03.04,Revised 1.26.05,Revi -. . .1 Revised 11/30/12
16E9
MEMORANDUM
Date: September 24, 2015
To: Kathy Heinrichsberg, Executive Secretary
Bureau of Emergency Services
From: Martha Vergara, Deputy Clerk
Minutes & Records Department
Re: COCPN & Permit
Ambitrans Medical Transport, Inc.
Attached is a one (1) copy of the COCPN and an original permit along with one (1)
certified copy of the documents referenced above, (Item #16E9) approved by the
Board of County Commissioners on Tuesday, September 22, 2015.
The original COCPN and a copy of the Permit have been kept by the Board's Minutes
and Records Department as part of the Boards Official Records.
If you have any questions, please contact me at 252-7240.
Thank you.
Attachments
16E9
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: 25 Ground Units available.
See Application 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.
n�
Issued and approved this aa. day ofSep-ke t-R—, 2015
• C h,,,
: d
ATTR': • BOARD OF COUNTY COMMISSIONERS
DWIGHT E. BROCK, LERK COLI—LINTY, FLORIDA
ePr-y(-1)10-Pli -(1.
A St as to Chalrt a put C11 Tim Nance, Chairman
signature ark:, , .,
Approved as to form and legality:
Jenni er A. Belped
Assistant County Attorney 097
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