HomeMy WebLinkAboutCity of Tamarac Resolution R-86-450Introduced by: 6��-�_ Temp. Reso. #4414
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CITY OF TAMARAC, FLORIDA
RESOLUTION NO. R-86-2�Lo
A RESOLUTION APPROVING AND AUTHORIZING THE
APPROPRIATE CITY OFFICIALS TO EXECUTE AN
AGREEMENT BETWEEN THE CITY OF TAMARAC AND
MEDICS AMBULANCE SERVICE, PERTAINING TO
AMBULANCE SERVICE; AND PROVIDING AN
EFFECTIVE DATE.
BE IT RESOLVED BY THE CITY COUNCIL OF THE CITY OF
TAMARAC, FLORIDA:
SE '.1QN__1: That the City Council of the Clay of Tamarac
hereby approves an Agreement between the City of Tamarac and
Medics Ambulance Service, pertaining to ambulance service
attached hereto and made a part hereof as Exhibit "A";
E T That the appropriate City Officials are
hereby authorized to execute said Agreement.
SECTIQN_3: This 'Resolution shall become effective
immediately upon adoption.
PASSED, ADOPTED AND APPROVED this / ° day of
1986.
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BERNA D HART
MAYOR
ATTEST:
LARRY PERRETTI
ACTING CITY CLERK
MAYOR: HART
DIST. 1: C/W MASSARO
I HEREBY CERTIFY that I have DIST, 2: V/M STELZER
approved the form and correct- DIST. 3: C/M GOTTESMAN
ness of this RESOLUTION. .�.�
DIST. 4: C/M STEIN
,PK
A. BRY T AP A y
CIT ATTORNEY
120386-01/rms
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AGREEME T
THIS AGREEMENT is made by and between the CITY OF
TAMARAC, a municipal corporation, hereinafter "CITY", and
MEDICS AMBULANCE SERVICE, a Florida corporation, hereinafter
"CONTRACTOR".
W I T N E S S E T H
WHEREAS, the City Council of the City of Tamarac has
determined that it is in the best interest of the CITY to
enter into an Agreement to provide ambulance service on a
contract basis with a private provider to the citizenry of
the City; and
WHEREAS, CONTRACTOR desires to provide the services on
the terms described herein; and
WHEREAS, CONTRACTOR possesses the necessary certificates
of convenience and necessity, permits and other governmental
approvals in order to conduct the business of ambulance
service in "Ambulance Zone 2" as established pursuant to the
laws of Broward County, Florida, which Zone includes all the
territory of the CITY:
NOW, THEREFORE, in consideration of the mutual covenants
contained herein, the parties agree as follows:
(a) Fner4eDgy Ambu2japg-e—C Any call for ambulance
service received or placed through the "911 System"
excluding "Baker Act" emergencies, in Broward
County or pursuant to the request of a public
safety agency (through the 911 system) ig, an
emergency situation or as otherwise provided by the
rules and regulations promulgated under Chapter 3
1/2 of the Broward County Code, as the same may be
amended from time to time;
(b) Rosrd talc: The area hospitals in which ambulance
service is provided for by this contract shall be
1. University Community
2. Florida Medical Center
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3. Northwest Regional
(c) All residents of the City of
Tamarac, including residents of any nursing homes
located in the City of Tamarac.
(d) A response time consistent
with County standards.
ECT_ION 2. CQMPLIANCE WITH PPLJCU �E_UFLS_: CONTRACTOR
covenants that at the time of the execution of this Agreement
it is in compliance with all local, state and federal laws
regarding the business of ambulance service including, but
not limited to, Chapter 3-1/2 of the Broward County Code and
Chapter 401 Florida Statutes and the rules and regulations
promulgated under either or both of them, all as may be
amended from time to time, and CONTRACTOR shall keep valid
and in full force and effect such certificates of convenience
and necessity, permits, licenses and governmental approvals
as shall be necessary to maintain such compliance during the
term of this Agreement.
SECTION]__3. P CONTRACTOR shall
maintain any and all certificates, licenses and approvals of
governmental agencies which are pre -requisites to the
maintenance and delivery of ambulance service in Broward
County, Florida and CONTRACTOR shall make available to the
CITY and allow the CITY to inspect any and all ambulances
which the CONTRACTOR uses in the CITY, and in the event any
defect is noted in such ambulances, such defect sha-1.1 be
cured immediately. In the event that the CONTRACTOR shall
fail to. keep in full force and effect the required
certificates, licenses and approvals, this Agreement shall be
deemed automatically terminated upon the expiration or
revocation of any such certificates, licenses and approvals.
BMIDIT 4. Bfty=: CONTRACTOR shall provide the
following:
(a) _1ulncQ Service. Emergency ambulance
service to all citizens of the CITY from any point
-2-
within the City limits of the City of Tamarac,
Broward County, Florida, to any of the above
defined hospitals in Broward County, without cost
to such citizens, except as may be set forth
herein.
(b) fte".r-aphic Lixnite: The corporate limits of the
City of Tamarac.
(c) =e_ditic_us_ _annd Non-discrigi ngtgry,_„_Manner: All
services denominated herein (911 calls) shall be
performed and provided in an expeditious and
professional manner without discrimination as to
race, color, creed, handicap, religion, sex,
national origin or ability to pay or availability
of insurance coverage.
SECTION. CWTRACT TERM AND PAYMENT: This Contract
shall be for a period of eleven (11) months starting on the
1st day of January, 1987 and ending on the 30th day of
November, 1987. CITY shall provide payment to contractor for
the eleven month period in the amount of $88,000.00. Payment
shall consist of the CITY transferring title to two vehicles,
more particularly described in Exhibit "A", attached hereto
and made a part hereof, to CONTRACTOR. If, for any reason,
this Contract shall terminate prior to the 30th day of
i
November, 1987, CONTRACTOR shall reimburse CITY the pro rated
amount of the $88,000.00 (or the market valuation) on a per
day basis from the day of termination to the 30th day of
November, 1987.
The CITY shall have the option of renewing this
Contract with the CONTRACTOR for a period of ten (10) months
commencing on the first day of December, 1987. The payment
. for the ten (10) month option period option period shall be
$84,000.00 payable on a monthly basis. If the CITY
determines that the CONTRACTOR should be granted the option
period of ten (10) months, commencing on December 1, 1987, it
shall adopt a Resolution approving the Contract terms and
amount of $84,000.00 as set forth herein.
-3-
The CITY shall have an option of granting an additional
twelve (12) month extension of the Contract to CONTRACTOR
commencing on October 1, 1988 and ending on September 30,
1989 for the Contract sum of $105,840.00, payable on a
monthly basis.
If the CITY determines that the CONTRACTOR should be
granted the option period of twelve (12)'months, commencing
on October 1, 1988, it shall adopt a Resolution approving the
Contract terms and amount of $105,840.00 as set forth herein.
,SECTION 6. RRE r�RSEMENT ANI? ADJUSTMENT:
(a) With respect to each person enjoying the services
to be provided hereunder, CONTRACTOR shall solicit
" and accept assignments of the recipient's insurance
protection benefits where available, and CONTRACTOR
shall make a good faith effort to obtain the
maximum potential insurance benefit payments from
the applicable insurers. The contract sum
described in SECTION 5 hereof shall be adjusted
.
annually, or earlier in the event of termination as
provided herein from insurance benefits payments
and such payments shall be distributed as follows:
CONTRACTOR shall receive the first 140,000.00;
hereafter any insurance benefit payments in excess
of $140,000.00 shall be divided equally between the
CITY and the CONTRACTOR.
(b) The parties intend that the adjustment described in
Sub -section (a) hereof be made annually, but with
due regard to normal delays in actual collection
delay of sixty (60) or more days from the date of
invoice to the applicable insurance carrier.
Therefore, it is understood between the parties
that such adjustment will focus on the contract
year in which the service was rendered, rather than
the year in which the collection was made;
provided, however, that in the interest of
expediting the CITY'S business, the accounting for
-4-
revenue is generated from services delivered in a
prior year, concerning the adjustment be made for
such prior year, shall be discontinued as of ninety
(90) days following the applicable annual term, and
the revenues collected thereafter shall be treated
as if collected upon services rendered in the then
current annual term.
(c) Notwithstanding anything to the contrary contained
herein, and particularly nothwithstanding, the
ninety (90) day cutoff date for accounting purposes
as set forth in sub -section (b) hereof, final
adjustment shall be made based upon the aggregate
of all insurance proceeds and revenues collected
from services rendered in connection with the
performance of this Agreement by the CONTRACTOR.
These provisions shall survive the termination of
this Agreement with respect to the receipts and
. disbursements, if any, and all insurance benefit
payments received by CONTRACTOR in connection with
service provided hereunder. Moreover, the
reimbursables due to a prior contract year shall
continue to be due and payable without regard to
the making of this Agreement.
5FXT_1ON J_NBD2A=: CONTRACTOR shall provide to the
CITY certificates of general liability, malpractice and
workers compensation insurance in such amounts as shall be
required by law, and each of such certificates shall provide
that the CITY is a co-insured under the named policy and that
such policy shall not be cancelled except upon a thirty (30)
day prior notice to he CITY. CONTRACTOR shall keep such
policies of insurance in full force and effect during the
term of this Agreement and shall provide to the CITY such
evidence of premium payment as the CITY shall require from
time to time.
CONTRACTOR shall hold CITY harmless from and indemnify CITY
-5-
from any and all claims, causes of action, damages, costs,
expenses and attorney's fees which the CITY shall suffer by
virtue of the defense of or response to any claim being made
against it in connection with the service to be rendered by
the CONTRACTOR, its agents or employees, hereunder or any act
or omission of CONTRACTOR, its agents or employees, in
connection therewith. This provision shall survive the
termination of this Agreement and shall pertain to any
occurrence during the term of this Agreement, even though the
claim may be made after the termination hereof.
SECTION 9. RECORDS AND REPORTING: CONTRACTOR agrees
that it shall keep accurate and complete records with regard
to all service provided hereunder. CONTRACTOR shall make his
books and business records available to the CITY for
inspection during normal business hours or upon twelve (12)
hours notice by the CITY, at the authorization of the City
Manager. CONTRACTOR shall provide to the City Manager of
the CITY a monthly report which shall describe the volume of
•
calls for service, the type of calls, response time, the
location of origination (point of pick-up) and conclusion
(point of patient delivery) with respect to such service
calls, the number of calls which terminated before actual
pick-up service was provided. Each monthly report shall
state separately the information for the month for which the
report is made and the cumulative information for the full
term to the date of report.
SECTION 10. All disputes
concerning level of service or any matter referred to herein
will be referred to the City Manager of the City of Tamarac,
or his designee, who shall conduct such investigations and
inquiries, including discussions with the CONTRACTOR which
the City Manager deems appropriate; the City Manager, or .his
designee, shall be the sole judge of the merits of the
dispute and the CONTRACTOR shall abide by the decision of
the City Manager.
KI
0
EECTI "I. I-N3P-F_CT10NS: The CONTRACTOR shall allow
the CITY to inspect all ambulances operating in the CITY at
any reasonable time as authorized by the City Manager, and
shall promptly remedy any deficiency noted by the CITY
inspection. All inspections will be pursuant to criteria
established by Florida Statutes 401 and by the Emergency
Medical Service (EMS) Division of Broward County.
SECTIOF___2. ,QFVF_R�SBi-1P ANP, ON TICS CONTRACTOR
acknowledges that the only stockholder(s) and officer(s) of
the CONTRACTOR is/are: Malcolm M. Cohen. The delivery of any
items and the giving of notice in compliance with the terms
of this Agreement shall be accomplished by making same, in
writing; and by the delivery thereof to the party intended to
receive it or by mailing the same to the address of such
party as hereinafter set forth. In the event such notice is
made by mail, the same shall be given via. U.S. Mail, return
receipt requested, and unless otherwise provided herein,
notice or delivery by mail shall be effective when mailed.
CITY OF TAMARAC
5811 N.W. 88th Avenue
Tamarac, Florida 33321
MEDICS AMBULANCE SERVICE
1776 E. Sunrise Boulevard
Ft. Lauderdale, Fla. 33304
SECT�Q�1.1 This Agreement shall commence on the 1st
day of January, 1987, and shall end on the 30th day of
November, 1987, unless otherwise terminated hereunder.
MUN TrON: Either party hereto may
terminate this Agreement on not less than ninety (90) days
written notice to the other party, unless otherwise provided
for herein.
SZJ'TION 15. 65S]M NTS: This Agreement shall not be
assigned by CONTRACTOR without first obtaining written
approval from CITY pursuant to Council action at a formal
meeting.
,SECTION, _„16. AMENDMENTS: This Agreement shall be
-7-
amended only by the proper execution of a written document of
equal dignity hereto previously approved by both parties.
,9FQT1QN 17. VENUE: In connection with any litigation
arising hereunder, venue shall be set in Broward County,
Florida.
,9ZCT�ON 18. DEFAULT: Failure on the part of the
CONTRACTOR to comply with any provision set forth herein may
be considered breach of this Agreement on the part of
CONTRACTOR and may be grounds for immediate cancellation on
the part of the CITY.
IN WITNESS WHEREOF, the parties have hereunto set their
hands and seals on the day and year set forth below their
respective signatures.
Witnesses:
J
LARRY PERRETTI
Acting City Clerk
Approved as to form:
A. BRYANTfAPPLEGATE
City Attorney
Witnesses:
-11A hc k t7 t , .c r—
CITY OF TAMARAC
y-
BERNARD HART, MAYOR
-at
This day of , 1916
,70HN KELLY, T MANAGER
This , day of -fi t/, 19 RO
MEDICS AMBULANCE SERVICE
By— t7sl r'04—t. -a•p
This day of &tLuK VX 19
(SEAL)
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STATE OF FLORIDA )
) ss..
COUNTY OF BROWARDQq-
)
I HEREBY CERTIFY that on this �- day of
198 Lp before me personally appeared BERNARD HART, JOHN KELLY,
LARRY PERRETTI, Mayor, City Manager and Acting City Clerk,
respectively, of the City of Tamarac, a municipal corporation of
Florida, and they acknowledged that they executed the foregoing
instrument as the proper City officials of the City of Tamarac,
Florida, and the said is the act and deed of said City of
Tamarac. �r
WITNESS my hand and official seal at L_'x''�'!r- in
the State and County aforesaid this day o % ,':� 1--19 LKe
Notary Public, State of
Florida -at -Large
My Commission Expires:
VIM OF FLORIDA IM PUPLIC STATE Of FLORIDA
C; L'G"1._5,?0': Ex^ SEPT 17,1990
• ) ss .: onl:_" THP.L' GENERAL INS, UNO.
COUNTY OF BROWARD ) A
I HEREBY CERTIFY that on this �_ dayof 1� .0 i�,
n 1"X �1wW
19%,, before me personally appeared%. (.� �t r , to me
known, who, being by me duly sworn, did depose and say that he is
the President of MEDICS AMBULANCE SERVICE, the corporation
described in and which executed the foregoing Agreement; that he
knows the seal of said corporation; that one of the impressions
affixed to said Agreement is an impression of such seal; that he
is the proper official of said corporation designated to execute
such Agreement; that he has authority so to do, that he executed
same for and in behalf of said corporation, and that his act is
the act* and deed of said corporation.
WITNESS my hand and official seal at A"-Li—O % , in
the State and County aforesaid this day of
19 Lb.
� U- L.� r 1 Z . &L.
Notary Public, State of
Florida -at -Large
My Commission Expires:
NOTARY PUBLIC, STATE OF FLORIDA AT LARGE
W,'e COMKO SSION EXPIRES NOV. 6, 1987
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9ONOEU TOUGN MUaOSKk*ASffON. WC.
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EXHIBIT "A"
INTER - OFFICE MEMORANDUM
FIRE DEPARTMENT
TO: JOHN BELLY, CITY MANAGER
FROM: RAYMOND H. BRIANT, FIRE CHIEF
P-1-11
DATE: DECEMBER 8, 1986
SUBJ: LEGAL DESCRIPTIONS
REF: TWO (2) CITY -OWNED AMBULANCES
Tel I \\`�
DEC 8 - 1936
CITY MANAGER .
CITY OF TAMARAC
Attached are the legal descriptions for the City's two (2) ambulances.
The following data is applicable to the above -referenced vehicles:
MAKE: FORD MODEL: Custom III BODY TYPE: 138"x90"x68"
VEHICLE I.D. #M-725/1FDKE30L7EHCO2957 YEAR: 1984
MARE: FORD MODEL: Custom III BODY TYPE: 138"x90"x68"
VEHICLE I.D. #M-724/1FDKE30L5EHCO2956 YEAR: 1984
Should you desire additional information, please contact me.
RHB/vdw
Attachments:
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DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
EMERGENCY MEDICAL SERVICES
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BASIC LIFE SUPPORT VEHICLE INSPECTION FORM (CHAPTER 401.31 F.S.)
Service Name
i Inspection Date /^ J Phone ('o 1)
County �_ _ _ Type of inspection: initial ❑ Reinspection U Complaint
❑ Random ❑
VEHICLE INFORMATION: Transport .❑ Non
Transport ❑ Unit# Year/Makei Permit*
M1183E VINM � _
-_-_ Vehicle Type: 1 ❑
11,0 III ❑ Other ❑ tap 0
If reinapection: Date of previous Inspection: fDeficient Items: _
Rescue Equipment not applicable due to written agreement with
Date
Inspection Codln:
I - Items present and in working order
Fallure Criteria:
at Any shaded box marked 2 constitutes failure
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1A . Items placed on vehicle at time of Inspection • Any three unshaded boxes marked 2 constitutes failure
2 : Items not present or not In working order
I A. VEHICLE REQUIREMENTS
ter 316 i 401 F.S.
11 MEDICAL EQUIPMENT i
III RESCUE EQUIPMENT
Th(Che
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SUPPLIES (Chapter 401
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Lights
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1 Two Munr Trauma o!a WWri�s
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2 One Wrench, 12 IIK11at with Adluslape
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3 Twenly=mW Slefie Gei.i1 Pats
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5 Rdl Alu Fat
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6 Two One WICK& or blocks
5 One HaCktaw with 12 Inch places, t th
per Inch and bN can with tight
WrriosNola wilm
_Eight Trnngular Barldagec
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5 Tlras
B Pilenl Retlravllt
6 One Parr Pliers (12 Inch Vice grip
6 Vehrcle Iree d Nat t dents
g Two W R der Bahps
T One 51p Hammer with 15 inch rgltl
7 Two-wa Radio
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B. Spahr puprnent 10
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11 Two slowPleasure Its 4 tathlascopes
B O Fi re As41 witn 24 inch He a tlnd Peek
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Adult ¢ Pediatric)
ne g. O2e inch mmlmum wise r g bar (Bar alit
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12, wo artkels and wo to
la Two Pulows w1lh water prool Carrara ¢ pkOw
Iwo procaedrng items me aar11bl11ed
as a loictoie entry tool
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1e. Patient Raincovar
to OM crowbar, 51 inch with pinch pant
16. Long Same sperd ThrM traptl f7r
Equ
11 One bolt Culler , OF 103 Inch law opam
veleM
12 Shovel idw , pointed blade or fouing heavy
1B, Shell Spl/e Board ¢ Two Sire,- 01
duty anlrenchi 1po1)
1 S. TRANSPORT VEHICLE
REQUIREMENTS
equivalent
17. Two Sated Ba c
13 OM Double Aclron Tin Snips, a inch
Ls. Reps 100IN1 with anNa slvengih 51Ix) ka
_ ,KKK-A•1822A A Cha ter 401 F.S.
Ili wo orlsbI. •ygen anks 1" ` or • E
cylln"fs) with Regulalor end Gauge mrmmum
in a piotactrve pag
15 Two hard fats (meataig A.N.S.j. SBg.1
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per lank
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1B� O.ygen Alaflkt •Two each adult, 0►ejd i
infant
1S Two pail Sately Goggles (rtlaall ,N.S.1.;
2 Lghls Ever ncy
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L Ali -marls
20. Two sets of Natal annul" with IuW
a7 1 ttandai0)
17 Blarnal (large hek fire retardant
protocimn
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4 &hen
21. Portable 1lrueticxi with wldl bale typing and
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lent auuirn extrication
5 Intleled Suplbn (mxn mk,m 3r7()rryn p vac wrist
6 Heald All con__uonr
22. Two Hand Operated Bag Mask Reauscilalots '
1B Ore MsgiC Krole
to Two sale-;; bdi/
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7 Ins ansd O.ygen whin reguista ¢ wrench, tr ank
(Adult ¢ Peoratr c) wn1 pear narks IAdull, r`
C1do 6 Inlant)
20 Sprrng.ipapau center Punch
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23. Extnnkty Immopiu:atlm Dwicp Y
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22 Prun Sew, Net,vy
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9 Auad� lacy Sisal 6 Two Sllapg
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below the lmclurs) Phi above and
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to Two IV Calb Holders
2e Lower Extremity Traction SO I t h autp0/1
11 Two HP Ire S, its
12 Overhead Grab Rau
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25 Ora Sara Dbtabicel Kit
IF ABOVE ITEMS NOT CARRIED THE
FOLLOWING ITEMS MUST Of CARRIED ON
EACH UNIT
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13 Squad Bench ¢ TMsa Sals a Seal f3eus
26 Two -urn Shasta
27. FlasMi rat (2 D cau Batgres)
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2O. Cor"(1menlaiLzad Pneumatic Troueera
(Adult ¢ Peolelricj If l—him
PallnOr Pry AAa or Equivalent
3. Salary Goggles (Meets A.N.S.1. Z /7.1
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2g Foui YateIIM L'.suLe
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1. Letlfe/ Gaunlal GlOvet, ort0 pall
30 Oraph/ry sal Asides
GENERAL SANITATION: SATISFACTORY
UNSATISFACTORY (Explain) LJ
CREW CREDENTIALS: Name
E/P/ D CARDM
Minimum -One EMT d, 1•
EXPIRATION PATE
One Driver
P. Paramac 2. ..�..�
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E = EMT 3.
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This vah► Je LJ meets LJ does not meet the requirements set forth in Chapter 401, F.S., and Chapter 10D-66, F.A.C.
1, the undersigned representative of the above service, acknowledge receipt of a copy of this Inspection
form. In addition, I am aware
of the
discrepancies listed (if any) and understand that failure to correct the discrepancies will 4ubjggt jbe_sepjige and its authorized representatives to
co rective action and penalities in Chapter 401, F.S., 4Qd Chapter 1,OD66. F.A.C.
Copy of Inspection Received by (Person In Charge) �,. _ _ _. _ . _ .. r Irate
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Inspected By: , . -- _ _
Date
HRS Form 627, Jun 84 (Replaces previous edlljons)
/'•1 1REV . 6I87) STATE OF FLORIDA THIS FORM BECOMES A BALE AND USE TAX RECEIPT ONLY
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VEHICLE REGISTRATION AND VEHICLE REGISTRATION
3 MOTOR VEHICLE SALES AND USE TAX REPORT'
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00041 021
(Ap, Title, Sulu Too)
STATE PP,EV. REG. O'D. NEW USED ODOMETER
VEHICLE
1[DATEVEN1_1L1,AE
�23Al �� �v� USAGE r. Fri;xtlA�-
NAMC OF FIRST LIENHOLDER. (IF NO LIEN, ENTER NONE)
Owner's Address (Florltlla residential address of owner, If dllfueht from (above)
'
ADDRLSS:
DATE OF LIEN;
CITY•S ZIP CODE
REPLACEMENT TAG/DECAL
THE LICENSE PLATE AND/OR DECAL IDENTIFIED HERE HAS BEEN LOST, STOLEN, DESTROYED OR 1!
NAME OF SELLER. FLORIDA DEALER. OR OTHER PREVIOUS OWNER:
DEFACED. AND THE POLICE OR SHERIFF HAS BEEN NOTIFIED. DEFACED ITEMS ARE HEREWITH
r r
ADURpSS r
TAG NUMBER
DECAL NUMBER
7YER:
Al
CITY-STATE ZIP CODE I
!t I.1 �•• ��an Y �' 1•'I j' UNPAID TBALDANCE DUE SELLER, IBANK OR OTHERS. Y •
I lm 1 s '' 0 ' 60 '• ^
G
OEALLR LICENSE NO. SALES TAX REGISTRATION NO. ..
w INDICATE SALES OR USE TAX DUE AS PROVIDED BY .: t •.� /
CHAPTER 212, FLORIDA STATUTES. S
•� CONSUMER EXEMPTION CERTIF,,d •/SALES TAX REGISTRATION A
TRANSFER OF TITLE PURCHASER HOLDS VALID VEHICLE WILL BE .
EXEMPTION CERTIFICATE D USED EXCLUSIVELY
IS EXEMPT FRpM FOR RENTAL
FLORIDA SALES OR
USE TAX FOR THE •� l�Tlik h C1:"'I IW.LJti� 4
REASOHIS) CHECKED: d '
1
ElIIWE
HEREBY CERTIFY THAT INC MOTOR
VEHICLE TO BE TITLED WILL NOT BE OPERATED UPON THE PUBLIC HIGHWAYS OF THIS STATE. i
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IIWE HEREBY CERTIFY THAT IIWE LAWFULLY OWN THE ABOVE DESCRIBED MOTOR VEHICLE, AND MAKE APPLICATION FOR TITLE AND/OR REGISTRATION, FURTHER CERTIFYING THAT A PHYSICAL
EAAMINAI ION OF TffE VEHICLE HAS BCEN MADE AND THAT THE INFORMATION DESCRIBING IT HEREIN IS CORRECT. IIWE AFFIRM UNDER PENALTY OF PERJURY THAT THE INFORMATION HEREIN IS TRUE
ACID CORRECT TO THE bEST OF MY/OUR KNOWLEDGE AND BELIEF. IF APPLYING FOR A DUPLICATE TITLE OR TITLE THATHAS NOTBEEN RECEIVED BYME AND MUST HAVE BEEN LOST IN THE MAIL, IIWE
ACnLE THAT IF 114E OHIGINAL CERTIFICATE IS FOUND OR RECEIVED BY ME IN THk MAIL, UWE WILL PROMPTLY RETURN SAME TO THE DEPARTMENT. IF LIEN IS OCING RECORDED NOTICE IS HEREBY • )
GAEN TIIA7 7HEHE 15 AN EXISTING WIiIfTEN WrN INSTRUMENT INVOLVING THE MOTOR VEHICLE DESCRIBED ABOVE AND HELD BY LIENHOLDER SHOWN ABOVE. r '
(
SIGNATURE OF APPLICANT SIGNATURE OF PERSON AUTHORIZED TO SIGN FOR
SIGNATURE OF APPLICANT
LIENHOLDER'S DUPLICATE
SIGNATURE OF PERSON AUTHORIZED TO SIGN FOR
(NAME OF LIENHOLDER) (PERSON TO SIGN FOR)
\.j�
NOTARY SEAL
SWORN AND SUBSCRIBED TO BEFORE,M6
01 NOV 1 'S4
-THIS DAYQF It
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(NOTARY PUBLIC)
MY COMMISSION EXPIRES
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.:U+I (REV, 0183) STATE: OF FLORIDA THIS FORM BECOMES A SALE AND USE TAX RECEIPT ONLY
,yny OHSAIV•V rDA) f � ,APPLICATION FOR CERTIFICATION OF TITLE AND/OR , . WHEN VALIDATED IN THIS AREA. ,
VEHICLE REGISTRATION AND
3t. VEHICLE REGISTRATION.
(': i .:.MOTOR VEHICLE SALES AND,USE TAX REPORT.:.;) �•) ;; h Y i:.:. -. ll.) 1��,IS.:: 1•liilf;/•,I.'
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',L'I F,.:ii.lar: 'ONLY:' ••I••• :�rl ;la r.':Il,rr•1•i:; N.r it 1. JII Iv! ll.flH3 A
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ORIGINEW j' '
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DECAL NUMBER •. .'•I :. ,hr.141•:.
S i I i �. .,. 1. i• - TAG�NUMBER *.+t''!�).
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/ DECAL . , E • BIRTHDATE ,+.) •: • EXPIRES ' ,',,_I.OWNER 'TRANS,.� r� .'�• I ' (• TAG l Ii
YR,
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ISSUED X MO. DAY VA, 1MO, DAY YR,,. /�•�IDDE�NT.. CODE, TFR., FEE ISSUED ;• l� �'�/�C� C/)IJ i
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-_ITLa kUl(Q' .,y VEHIC``LE IDENTIFICATION ND. YR. MAKE i WT/LENGTH .j1 CCASS jf� GVW)LOC
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w nor L N.mr i Adtlnn to wnlCn lu4 is it be mood. II P.O. Bak h und. •trgl.dd/•.. mu.I Or shown lil OWNER OIL NO. 2nd OWNER OIL NO.
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1 INSURANCE DATE S 1
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' ' �'+••••• •• •.•1•l;l�+rs:.+.l�l: 'PIP LIAUILITY, CREDITS REFUNDS ,MO DAY. YR.
•i= Ni:)��AC FL 73321 � ...X 5. 00 0'1; 0 '11.. 0j F3
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r�I r1,J;. rl j1? + 1.. CREDIT VEHICLE 1
MOS TAX S B.T. MOS. , BACK TAX S' • SVC. CHG. 5 OTHER CHARGES $ TAG TOTALS MO. CLASS WTA ENOTH•
TAG MONEY 1� 1'
',.rppr� .rrJ (•� .
I- REV L 9
a i� a 0l� 1, w'2V: 0 • rJ �1 w! it! w
TITLE FEE S/�yy LATE PENA/L�TY S rr LIEN $/y SVC. ONG, S r TITLE TOTAL S SALES TAX TOTAL S GRAND TOTAL S
TITLE MONEY u . 6 ci n U1� 0 11 N lJ 3 u oc L'] ,. w rrl . 60 1.1 r %:�
q /� //��+P � /„'
V 4031) � 02 .-
(rrp, Tuu, s.L, r..)
'ATE PREY. REG.
DATE VEHICLE ACO'D,
NEW
DOMETER
VEHICLE
•
i t �1
10.;�;. (311
•y
X
IFUSED
�r�
1 100 �
r� q �` �I
USAGE �,;, pf,IVA i•E '
AME OF FIRST LIENHOLDER: (IF NO LIEN, ENTER NONE)
Owner's Address (Florid. rrrlarnlld address of owner. 11 dlRurm (rem .hors)
OGRESS•
PATE OF LIEN:
TY•STATE ZIP CODE
REPLACEMENT TAG/DECAL
THE LICENSE PLATE ANDIOR DECAL IDENTIFIED HERE HAS BEEN LOST, STOLEN, 0E3TROYE0OR •
AME OF SELLER, FLORIDA DEALER, OR OTHER PREVIOUS OWNER:
.DEFACED, AND THE POLICE OR SHERIFF HAS BEEN NOTIFIED. DEFACED ITEMS ARE HEREWITH
V17 1• Nc
SURRENDERED.
]DRESS.
TAG NUMBER
DECAL NUMBER
YEAR:
TY•STATE ZIP CODE
`) tCAA p?+�� ( INDICATE TOTAL PRICE. Y - , UNPAID BALANCE DUE SELLER, OR OTHERS. 00
rLER LICENSE NO. r SALES TAX REGISTRATION NO,
INDICATE SALES OR USE TAX DUE AS PROVIDED BY $' '
CHAPTER 212. FLORIDA STATUTES.
• TRANSFER OF TITLE PURCHASER MOLDS VALID CONSUMER EXEMPTION CERTIF, 1( VESALES TAX REGISTRATION A
HICLILL BE
EXEMPTION CERTIFICATE ❑ USEE W
D EXCLUSIVELY
IS EXEMPT FROM FOR RENTAL
FLORIDA SALES OR
pI� r
USE TAX FOR THE �;IQTHFR (1-.Y,PL_A.TN,)
REASON(S)CHECKED:
IveE HEREBY CERTIFY THAT
THE MOTOR VEHICLE TO BE TITLED WILL NOT BE OPERATED UPON THE PUBLIC HIGHWAYS OF THIS STATE.
WE HEREBY CERTIFY THAT IIW E LAWFULLY QWN THE ABOVE DESCRIBED MOTOR VEHICLE, AND MAKE APPLICATION FOR TITLE AND/OR REGISTRATION, FURTHER CERTIFYING THAT A PHYSICAL
.(AMINAIIONOFTHE VEHICLE HAS BEEN MA IJDTHATTHEINFORMATIONDESCRIBINGITHEREINISCORRECT.IIWEAFFIRMU14DERPENALTYOFPERJURYTHATTHEINFORMATIOHHEREINISTRUE
NO LORIMCI TO THE ULST OF MY/OUR KNOWLEDGE AND ULLIEr, IF APPLYING FOR A DUPLICATE TITLE OR TITLE THAT HAS NOT BEEN RECEIVED UY ME AND MUST HAVE BEEN LOST IN THE MAIL. IIW E
GnLE Ir1Al IF T11L ORIGINAL CEIII IHCA1E I$ FOUND OR RECEIVED BY ME IN THE MAIL. IIWE WILL PROMPTLY RETUHN SAME TO THE DEPARTMENT. IF LIEN IS BEING RECORDED NOTICE IS HEREBY
IVEN THAI IHEHL IS AN EXISTING WRITTEN LIEN INSTRUMENT INVOLVING THE MOTOR. VEHICLE DESCRIBED ABOVE AND HELD UY LIENHOLDER SHOWN ABOVE.
0
SIGNATURE OF APPLICANT
,SIGNATURE OF APPLICANT
�IEI. IOLDER•S DUPLICATE
\Q`
SIGNATURE OF PERSON AUTHORIZED TO SIGN FOR
SIGNATURE OF PERSON AUTHORIZED TO SIGN FOR
(NAME OF LIEN HOLDER) (PERSON TO SIGN FOR)
NOTARY SEAL
SWORN AND SUBSCRIBED TO BEFORE ME
01,
NOV
84
THIS . DAY OF ' 1B �.,
(NOTARY PUBLIC)
MY COMMISSION EXPIRES