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Backup Documents 09/28/2021 Item #16F 3 ORIGINAL DOCUMENTS CHECKLIST & ROUTING SLIP 1 6 F 3 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 Attomey Office. Route to Addressee(s) (List in routing order) Office Initials Date 1. 2. 3. County Attorney Office County Attorney Office ac aiatai 4. BCC Office Board of County 1Q Commissioners ,,./5 l' 5. Minutes and Records Clerk of Court's Office ` 64) Ituyima-1 rl�,f c 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 X3622 Contact/ Department Agenda Date Item was September 28,2021 Agenda Item Number Approved by the BCC 17843 (Minute Track)/ /6F Type of Document Certificate and Permit Number of Original 2 / Attached Documents Attached PO number or account 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? 5 O y` I 2. Does the document need to be sent to another agency for additional signatures? IT 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 KH 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 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 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 September 28,2021 and all changes made 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 cT 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 16F 3 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) 629-1009 Description of Service: Inter-facility and out-of-county transport for Collier County Number of Ambulances: (35)Thirty-Five(ALS ONLY) 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 554.41 day of SQ( , 2021 ATTEST: BOA' P OF OUNTY COMMISSIONERS CRYSTAL K. KINZEL COLL El" NTY. FLO CLERK p t as to Woos e uty Penny Taylor. hairman SlggApproved/as to form and legality: Jennifer A. Belpe OJ Assistant County Attorney S\ 16F 3 Ambitrans Medical Transport,Inc. 2021 Licensed Ambulance List Vehicle Identification Number License Type License Number Effective Date 1FDSS3ESODDA41561 VEHICLE PERMIT(ALS) 20888 8/24/2017 1FDSS3ESODDA41561 VEHICLE PERMITS(BLS) 4956 2/18/2016 1FDSS3ES1BDB27801 VEHICLE PERMIT(ALS) 17027 12/8/2011 1FDSS3ES1BDB27801 VEHICLE PERMITS(BLS) 5212 8/24/2017 1FDSS3ES3CDA18371 VEHICLE PERMIT(ALS) 20885 8/24/2017 1FDSS3ES3CDA18371 VEHICLE PERMITS(BLS) 4832 4/8/2015 1FDSS3ES4BDA26137 VEHICLE PERMIT(ALS) 20882 8/24/2017 1FDSS3ES4BDA26137 VEHICLE PERMITS(BLS) 4775 7/31/2014 1FDS53ES5CDA18372 VEHICLE PERMIT(ALS) 20886 8/24/2017 1FDSS3ES5CDA18372 VEHICLE PERMITS(BLS) 4954 2/18/2016 1FDSS3ES6ADA31208 VEHICLE PERMIT(ALS) 20880 8/24/2017 1FDSS3ES6ADA31208 VEHICLE PERMITS(BLS) 4678 8/1/2013 1FDSS3ES6BDB36820 VEHICLE PERMIT(ALS) 22521 10/1/2019 1FDSS3ES6BDB36820 VEHICLE PERMITS(BLS) 5940 10/1/2019 1FDSS3ES7BDB27799 VEHICLE PERMIT(ALS) 20883 8/24/2017 1FDS53ES7BDB27799 VEHICLE PERMITS(BLS) 4777 7/31/2014 1FDSS3ES7BDB27804 VEHICLE PERMIT(ALS) 17026 12/8/2011 1FDSS3ES7BDB27804 VEHICLE PERMITS(BLS) 5213 8/24/2017 1FDSS3ES8DDB02266 VEHICLE PERMIT(ALS) 20889 8/24/2017 1FDSS3ES8DDB02266 VEHICLE PERMITS(BLS) 4776 7/31/2014 1FDSS3ES9EDA22265 VEHICLE PERMIT(ALS) 20890 8/24/2017 1FDSS3ES9EDA22265 VEHICLE PERMITS(BLS) 4823 3/10/2015 1FDWE3FD7ADA20886 VEHICLE PERMITS(BLS) 5121 3/8/2017 1FDWE3FS4ADA62447 VEHICLE PERMIT(ALS) 20891 8/24/2017 1FDWE3FS4ADA62447 VEHICLE PERMITS(BLS) 5119 3/8/2017 1FDWE3FS5ADA20885 VEHICLE PERMIT(ALS) 20892 8/24/2017 1FDWE3FSSAOA20885 VEHICLE PERMITS(BLS) 5120 3/8/2017 1FDWE3FS6BDA87027 VEHICLE PERMIT(ALS) 20896 8/24/2017 1FDWE3FS6BDA87027 VEHICLE PERMITS(BLS) 4821 3/10/2015 1FDWE3FS7ADA20886 VEHICLE PERMIT(ALS) 20893 8/24/2017 1FDWE3FS7ADA69148 VEHICLE PERMIT(ALS) 18535 7/31/2014 1FDWE3FS7ADA69148 VEHICLE PERMITS(BLS) 5216 8/24/2017 1FDWE3FS88DA01958 VEHICLE PERMIT(ALS) 21048 10/25/2017 1FDWE3FS88DA01958 VEHICLE PERMITS(BLS) 5368 10/25/2017 1FDWE3FS8BDA09607 VEHICLE PERMIT(ALS) 18896 3/10/2015 1FDWE3FS8BDA09607 VEHICLE PERMITS(BLS) 5218 8/24/2017 1FDWE3FS9ADA34661 VEHICLE PERMIT(ALS) 19943 6/6/2016 1FDWE3FS9ADA34661 VEHICLE PERMITS(BLS) 5224 8/24/2017 1FDWE3FSXDDA26427 VEHICLE PERMIT(ALS) 23547 3/2/2021 1FDWE3FSXDDA26427 VEHICLE PERMITS(BLS) 6317 3/2/2021 1FDXE4FSOEDA55897 VEHICLE PERMIT(ALS) 22001 1/18/2019 1FDXE4FSOEDA55897 VEHICLE PERMITS(BLS) 5692 1/18/2019 1FDXE4FSOGDC00665 VEHICLE PERMIT(ALS) 22759 2/3/2020 1FDXE4FSOGDC00665 VEHICLE PERMITS(BLS) 6007 2/3/2020 1FDXE4FS2BDB29932 VEHICLE PERMIT(ALS) 19699 1/19/2016 ., 1FDXE4FS2BDB29932 VEHICLE PERMITS(BLS) 5220 8/24/2017 Exhibit"A" 1 1 6 F 3 Ambitrans Medical Transport,Inc. 2021 Licensed Ambulance List 1FDXE4FS2EDA12033 VEHICLE PERMIT(ALS) 23784 7/8/2021 1FDXE4FS2EDA12033 VEHICLE PERMITS(BLS) 6385 7/8/2021 1FDXE4FS2EDA55898 VEHICLE PERMIT(ALS) 22002 1/18/2019 1FDXE4FS2EDA55898 VEHICLE PERMITS(BLS) 5693 1/18/2019 1FDXE4FS2GDC00666 VEHICLE PERMIT(ALS) 22760 2/3/2020 1FDXE4FS2GDC00666 VEHICLE PERMITS(BLS) 6008 2/3/2020 1FDXE4FS3BDB29941 VEHICLE PERMIT(ALS) 19758 2/18/2016 1FDXE4FS3BDB29941 VEHICLE PERMITS(BLS) 5222 8/24/2017 1FDXE4FS3BDB35786 VEHICLE PERMIT(ALS) 19759 2/18/2016 1FDXE4FS3BDB35786 VEHICLE PERMITS(BLS) 5223 8/24/2017 1FDXE4FS4BDB35781 VEHICLE PERMIT(ALS) 19757 2/18/2016 1FDXE4FS4BDB35781 VEHICLE PERMITS(BLS) 5221 8/24/2017 1FDXE4FS5EDA77930 VEHICLE PERMIT(ALS) 23534 2/23/2021 1FDXE4FSSEDA77930 VEHICLE PERMITS(BLS) 6312 2/23/2021 1FDXE4FS6CDA90604 VEHICLE PERMIT(ALS) 19956 6/20/2016 1FDXE4FS6CDA90604 VEHICLE PERMITS(BLS) 5225 8/24/2017 1FDXE4FS8BDB35783 VEHICLE PERMIT(ALS) 19957 6/20/2016 1FDXE4FS8BDB35783 VEHICLE PERMITS(BLS) 5226 8/24/2017 1FDXE4FS8GDC04320 VEHICLE PERMIT(ALS) 23009 6/5/2020 1FDXE4FS8GDC04320 VEHICLE PERMITS(BLS) 6112 6/5/2020 1FDXE4FSDDA34901 VEHICLE PERMIT(ALS) 23548 3/2/2021 1FDXE4FSDDA34901 VEHICLE PERMITS(BLS) 6318 3/2/2021 1FDXE4FSXGDC04321 VEHICLE PERMIT(ALS) 23010 6/5/2020 1FDXE4FSXGDC04321 VEHICLE PERMITS(BLS) 6113 6/5/2020 v I 16F 3 4.611*fila 4I",�way�► )i) f1+fir` area, i�' •� • • , '' � •Eu r >tn z ec'a C a r / F C t u . 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