Backup Documents 01/27/2009 Item #16F 4
ORIGINAL DOCUMENTS CHECKLIST & ROUTING SLIP 16 F J.
TO ACCOMPANY ALL ORIGINAL DOCUMENTS SENT TO 5ofo
THE BOARD OF COUNTY COMMISSIONERS OFFICE FOR SIGNATURE
Print on pink paper. Attach to original document Original dncumcl1ls should be hand delivered to tht, Board Of11cc T'he completed routing slip and original
documents are to be forwarded to the Board Office only aftc.! the Blldrd has taken action on the item]
ROUTING SLIP
Complete routing lines #1 through #4 as appropriate for additional signatures, dates, and/or infonnation needed. If the document is already complete with the
exception of the Chairman's sil!I1ature, draw a line throu2h routine: lines # I throuDh #4, comnletc the checklist, and forward to Sue Filson (line #5)
Route to Addressee(s) Office Initials Date
(List in routing order)
1.
---......,.
2.
.... - " -.
3.
, ._.~- "-",_.,.-.
4. ,-'.'- ,--,,-,_.._---,~.,.~"
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5. Sue Filson, Executive Manager Board of County Commissioners
6. Minutes and Records Clerk of Court's Office
PRIMARY CONTACT INI<'ORMATION
(The primary contact is the holder of the original document pending HCC approval. Nonnally 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 statTfor additional or missing
information. All original documents nceding the Bee Chairman's signature are to be delivered to the Bee office only after the BCC has acted to approve the
item)
Name of Primary Staff Artie Bay Phone Number 252-8459
Contact
Agenda Date Item was 1/27/09 Agenda Item Number 16F /1
Approved by the BCC
Type of Document Class B COPCN Permit and Certificate Number of Original I (M & N - Please
Attached Documents Attached return oril,inals)
1.
INSTRUCTIONS & CHECKLIST
Initial the Yes column or mark "N/ A" in the Not Applicablc column, whichever is
a TO nate.
Original document has been signed/initialed for legal sufficiency. (All documents to be
signed by tbe 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. tbat have been fully executed by all parties except the BCC
Chairman and Clerk to tbe Board and ossibl State Officials.)
All handwritten strike-through and revisions have been initialed by the County Attomey's
Office and all otber arties exce t the BCC Chairman and the Clerk to tbe Board
The Chairman's signature line date has been entered as the date of BCC approval of the
document or tbe final ne otiated contract date wbichever is a licable.
"Sign here" tabs are placed on the appropriate pages indicating where the Chairman's
si ature and initials are re uired.
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.
Some documents are time sensitive and require forwarding to Tallahassee within a certain
time frame or the Bce's actions are nullified. Be aware of your deadlines!
The document was approved by the BCC onJ [' '\!j'(enter date) and all changes
made during the meeting have been incorporated in the attached documenL The
Coun Attorne's Office has reviewed the chan es, if a Iicable.
Yes
(Initial)
N/A(Not
A licable)
2.
3.
4.
5.
6,
I P
r ' .
. ,
,'. ' .
I: Fonns! County Fonns! Bee Forms! Original Documents Routing Slip WWS Original 9.0.3.04, Revised 1.26.05, Revised 2.24.05
16F4
MEMORANDUM
Date:
January 28, 2009
To:
Artie Bay
EMS, Operations Analyst
From:
Teresa Polaski, Deputy Clerk
Minutes & Records Department
Re:
Permit and Certificate
Attached please find one (1) original of each document referenced above, (Agenda
Item #16F4) approved by the Collier County Board of County Commissioners on
Tuesday, January 27, 2009.
If you have any questions, please call me at 252-8411.
Thank you.
----------.-~---...--~-'"'..""
16F4
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: Intrafacility and out of county transport for the NCH Healthcare
System
Number of Ambulances: 3 Ground Units; NCH will operate no less than one (]) 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 operation intrafacility 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 any local, state or
federal laws or regulation application to the provisions of Emergency Medical Services.
Issued and approved this )71h
day of "'l(lIillO(l!
f
,2009
. ~i"',
A TTES:r\' '.' .. :)" 0
DWIGHT E. BRQCK,CLERK
~fQ(a~~~(~L
~ep~\\~F~t~)CItoiI"" ,
'I~~~ ~l.
Approved as to form and legal sufficiency:
BOARD ~ COUNTY COMMISSIONERS
COLLI(jL OUNTY, FLO,.D,,:
~I~ d;.--t..~
Donna Fiala, Chairman
~~w~
Jenmfer B. White
Assistant County Attorney
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