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Backup Documents 10/11/2016 Item #16E 5
ORIGINAL DOCUMENTS CHECKLIST & ROUTING SLIP TO ACCOMPANY ALL ORIGINAL DOCUMENTS SENT TO THE BOARD OF COUNTY COMMISSIONERS OFFICE FOR SIGNATU 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 11(00 4. BCC Office Board of County Commissioners v'I4NZ oA\Z,lb 5. Minutes and Records Clerk of Court's Office (0634 q:5904n 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 Phone Number 252-3622 Contact/ Department Kathy Heinrichsberg,Executive Secretary Agenda Date Item was October 11,2016 ✓ Agenda Item Number Approved by the BCC 16E5 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 signatur STA ' OK KH 2. Does the document need to be sent to another agency for .dditional signature . If yes, KH N/A provide the Contact Information(Name; Agency;Address; • •- •i .• . ached 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 KH 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 ..I(eIf should be provided to the County Attorney Office at the time the item is input into SIRE. 'Wle\ 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 October 11.2016 and all changes made KH during the 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 • 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 16E 5 MEMORANDUM Date: October 14, 2016 To: Kathy Heinrichsberg, Executive Secretary Bureau of Emergency Services From: Ann Jennejohn, Deputy Clerk Minutes & Records Department Re: Annual Certificate of Public Convenience and Necessity (COPCN) Permit and Certificate for Ambitrans Medical Transport, Inc. Please find the original copies of the documents referenced above (Item #16E5) approved by the Board of County Commissioners on Tuesday, October 11, 2016. Copies of the permit and certificate will be held in the Minutes and Records Department for the Board's Official Record. If you have any questions, please contact me at 252-8406. Thank you. Attachment 16E 5 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: (33)Thirty-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 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 1 % day of b c,#o b e 2 ,2016 A I hST: BO OF COUNTY COMMISSIONERS DWIGHT E. BROCK, CLERK CO R COUNT ,FLORIDA bj: Clerk Donna Fiala, Chairman Attest as to Chairman's AppAppflinatillegligtm and legality: CAJC- Jennifer A. Belpedi Assistant County Attorney2�� Item# Agendate l.Ttktr `,_�0 Da Reed ieputy 1 6E 5 :, Attachement A Ambitrans Medical Transport,Inc. List of Vehides in Fleet-2016 Name License Type License Effective Date 1FDSS3ESODDA41561 VEHICLE PERMITS(BLS) 4956 2/18/2016 1FDSS3ES1BDB27801 VEHICLE PERMIT(ALS) 17027 12/8/2011 1FOSS3ES3BDA26145 VEHICLE PERMITS(BLS) 4355 2/24/2011 1FDSS3ES3CDA18371 VEHICLE PERMITS(BLS) 4832 4/8/2015 1FOSS3E54BDA26137 VEHICLE PERMITS(BLS) 4775 7/31/2014 1FDSS3ES5ADA25626 VEHICLE PERMITS(BLS) 4677 8/1/2013 1FDSS3ES5CDA18372 VEHICLE PERMITS(BLS) 4954 2/18/2016 1FDSS3ES6ADA31208 VEHICLE PERMITS(BLS) 4678 8/1/2013 1FDSS3ES6BDA26138 VEHICLE PERMITS(BLS) 4475 3/29/2012 1FDSS3ES6BDB36820 VEHICLE PERMITS(BLS) 4955 2/18/2016 1FDSS3ES7BDB27799 VEHICLE PERMITS(BLS) 4777 7/31/2014 1FDSS3ES7BDB27804 VEHICLE PERMIT(ALS) 17026 12/8/2011 1FDSS3ES70DB06017 VEHICLE PERMIT(ALS) 18017 7/23/2013 1FDSS3ES8DDB02266 VEHICLE PERMITS(BLS) 4776 7/31/2014 1FOSS3ES9EDA22265 VEHICLE PERMITS(BLS) 4823 3/10/2015 1FDWE35F92HA44797 VEHICLE PERMITS(BLS) 4133 12/19/2007 1FDWE3FS1ADA32547 VEHICLE PERMIT(ALS) 18534 7/31/2014 1FDWE3FS3ADA32551 VEHICLE PERMITS(BLS) 4822 3/10/2015 1FDWE3FSSADA69150 VEHICLE PERMIT(ALS) 18536 7/31/2014 1FDWE3FS6BDA87027 VEHICLE PERMITS(BLS) 4821 3/10/2015 1FDWE3FS7ADA69148 VEHICLE PERMIT(ALS) 18535 7/31/2014 1FDWE3FS7BDA91166 VEHICLE PERMIT(ALS) 18895 3/10/2015 1FDWE3FS8BDA09607 VEHICLE PERMIT(ALS) 18896 3/10/2015 1FDWE3FS9ADA34661 VEHICLE PERMIT(ALS) 19943 6/6/2016 1FDWE3FSXADA32546 VEHICLE PERMITS(BLS) 5037 8/25/2016 1FDWR3FSXBDA09608 VEHICLE PERMIT(AU) 19338 8/24/2015 1FDXE4FS2BDB29932 VEHICLE PERMIT(ALS) 19699 1/19/2016 1FDXE4FS3BDB29941 VEHICLE PERMIT(ALS) 19758 2/18/2016 1FDXE4FS3BDB35786 VEHICLE PERMIT(ALS) 19759 2/18/2016 1FDXE4FS4BDB35781 VEHICLE PERMIT(ALS) 19757 2/18/2016 1FDXE4FS6CDA90604 VEHICLE PERMIT(ALS) 19956 6/20/2016 1FDXE4FS8BDB35783 VEHICLE PERMIT(ALS) 19957 6/20/2016 1FOXE4FS9EDA75257 VEHICLE PERMIT(ALS) 18361 5/6/2014 _ A 1 y,+ '��)- „fib ',�"'s -SI •)r: ap"tr"�l4 S '> •r'-.. - 'iY 'St • /(\e"--;1 1 ` o b/�,a -5 U • Z. 11 \7 ov •pOO % dn y L, u • l V s . a' _Z Cd - w �Ic .( a - 0 y�l y CJ© g '4 .:t oE _ � L WC �\ (7 -s, z ; uIJJ 5 d `d' p e ,�, .� `o 0 0' w O O co i c '� y .> .y 6' a' O � U `' 0 3 E y y Q W i�. b > „r� rA GL i._', ,Q c 'rte' rd ), 0 y 5 �i ca k' ! /' W PC -. ea y., .5 ,.; e> E = 4) CO O W W - c p IE yy l w c is u E b a u 7 9/`v c c V Q g y 0 E a •a o • J U cd -c rfai 2 > p L. ,0 V Q rte. �. .. `�I z 1° i0 O E w V es v '':`,1 s c C N v p 04 w �' C a' co I%. r ; F. 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