Backup Documents 09/10/2019 Item #16E 4 ORIGINAL DOCUMENTS CHECKLIST & ROUTING SLIP 6
TO ACCOMPANY ALL ORIGINAL DOCUMENTS SENT TO 1 Egi
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 routingslines#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 `a/
9' /
4. BCC Office Board of County \-N`
Commissioners y A/ 'clk k}`\c
5. Minutes and Records Clerk of Court's Office q / ii IF, 3 iii'
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 Kathy Heinrichsberg Phone Number 239-252-3622 I Contact/ Department
Agenda Date Item was September 10,2019 - / Agenda Item Number 16E t8. 4/
Approved by the BCC V / /
Type of Document Permit and Certificate / Number of Original 2
Attached ��V Documents Attached
PO number or account
number if document is riAss_
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? - ►�^'� 0 KH
2. Does the document need to be sent to another agency for addit : al signatures? I -s, KH
provide the Contact Information(Name;Agency;Address;Phone)o : • : ed 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 KH
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 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 KH
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 ithin a certain
time frame or the BCC's actions are nullified. Be aware of your deadli s!
8. The document was approved by the BCC on September 10,2019 a changes made KH N/A is not
during the meeting have been incorporated in the attached document. The County an option for
Attorney's Office has reviewed the changes,if applicable. ' line.
9. Initials of attorney verifying that the attached document is the version approved by t e KH b is not
it.
BCC,all changes directed by the BCC have been made,and the document is ready f the
ti
Chairman's signature.
Please Return to Kathy Heinrichsberg in Emergency Management \C
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 ^
16 E4
MEMORANDUM
Date: September 12, 2019
To: Kathy Heinrichsberg, Executive Secretary
Bureau of Emergency Services
From: Teresa Cannon, Sr. Deputy Clerk
Minutes & Records Department
Re: COPCN Permit and Certificate —Ambitrans Medical Transport,
Inc.
Attached is one (1) document as referenced above, (Item #16E2) as approved by the
Board of County Commissioners on Tuesday, September 10, 2019.
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 252-8411.
Thank you.
Attachment
1 6 E 4
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: (72) Seventy-two
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 ALS 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 I LI day of Sm 13-1-1).— , 2019
ATTEST: BOARD OF COUNTY COMMISSIONERS
� .i','OSI K. KINZEL COLLIER C e . NTY, FLORIDA
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Attest s to •
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