HomeMy WebLinkAboutCAG2021-242 - Original - Regional Animal Services of King County - Authorized Emergency Vehicle Permit Application - 04/29/2021 AUTHORIZED EMERGENCY VEHICLE PERMIT ago '&"
5 nr o
APPLICATION
DATE APPROVED:
VALID UNTIL:
CAPTAIN:
WASHINGTON STATE PATROL
EQUIPMENT & STANDARDS REVIEW UNIT
GENERAL ADMINISTRATION BLDG
PO BOX 42600 (For Department Use Only)
OLYMPIA WA 98504-2600
This application must be submitted by the Chief Executive of the firm or corporation making application.
Please type or print in ink.
Person, Company, Department, or Agency
(if a person, must list agency/department representing) Regional Animal Services of King County
Address 21615 64'h Ave S
City Kent State WA Zip 98032
Phone (206)263-5939 E-mail tim.anderson@kingcounty.gov
1. Purpose of Application/Authority: Describe below the specific purpose for which the vehicle(s)will be
used as authorized emergency vehicle(s)and what necessitates permitting as an authorized emergency
vehicle. The purpose should include the nature and scope of the duties, responsibilities, and intended uses
of emergency equipment, as well as the statutes that give authority for the listed equipment and uses.
King County employs Animal Control Officers(RCW 16.52.015 (2)(3)and King County Code U. 04.170)
who work under the Department of Executive Services in the Recording and Licensing Division. Animal
Control Officers respond to, investigate and take enforcement action on violations of local laws as well as title
16 of the RCW. As part of their scope of duty and responsibilities,Animal Control Officers respond to requests
from Law Enforcement and Fire,often these requests are related to traffic hazards or motor vehicle collisions in
which animals are involved and it is necessary for the Animal Control Officer to respond to the incident location
which may require maneuvering through stopped traffic or more frequently being in traffic with a hazard or on
the roadside requiring roadside safety, which would be the intended use of the emergency equipment,(WAC
204-36-30(2)(c)).
3000-323-006(R 6/15) Page 1 of 7
AUTHORIZED EMERGENCY VEHICLE PERMIT
APPLICATION w. jar,
3000-323-006(R 8115) Page 2 of 7
AUTHORIZED EMERGENCY VEHICLE PERMIT !
APPLICATION i j
2 Vehicle Information: List all vehicles intended to be used as authorized emergency vehicles. For each
vehicle, provide all vehicle and emergency equipment information as outlined below. Prior approval must be
given before utilizing a new vehicle or a vehicle with equipment installed other than what is authorized under
the current permit for that vehicle. Proof of insurance for each vehicle must be attached pursuant to WAC
204-36-030. If providing funeral escorts, proof of commercial insurance in Washington State or business
use exemption must be provided pursuant to WAC 204-36-040.
VEHICLE INFORMATION EMERGENCY EQUIPMENT INFORMATION
YEAR LICENSE NO. INSTALLED MAKE MODEL
2013 A3438C ✓ SIREN
MAKE MODEL ® LAMP(S)(location/colors)
FORD F250 REAR/RED
�• VIN FRONT/RED
1 F'I'7X2A69DEA26727
`REGISTERED OWNER ❑OTHER EQUIPMENT
I KING COUNTY DOT FLEET ADMIN
VEHICLE INFORMATION EMERGENCY EQUIPMENT INFORMATION
YEAR LICENSE NO. INSTALLED MAKE MODEL
2013 A3437C V ®SIREN
MAKE MODEL ® LAMP(S)(location/colors)
FORD F250 REAR/RED
2•'VIN FRONT/RED
I F I'7X2A60DEA26728
REGISTERED OWNER ❑OTHER EQUIPMENT:
i KING COUNTY DOT FLEET ADMIN
VEHICLE INFORMATION EMERGENCY EQUIPMENT INFORMATION
YEAR LICENSE NO. INSTALLED MAKE MODEL
20t3 A3451C ® SIREN
MAKE MODEL ®LAMP(S)(location/colors)
FORD F250 REAR/RED
3 VIN FRONT/RED
I FT7X2B60DEA26730
REGISTERED OWNER ❑OTHER EQUIPMENT:
KING COUNTY DOT FLEET ADMIN
VEHICLE INFORMATION EMERGENCY EQUIPMENT INFORMATION
YEAR LICENSE NO. _ INSTALLED MAKE MODEL
2014 A6068C 1/ ® SIREN
MAKE MODEL ® LAMP(S)(location/colors)
FORD F250 REAR/RED
4. VIN FRONT/RED
IFT7X2B61EEB67825
REGISTERED OWNER ❑ OTHER EQUIPMENT:
KING COUNTY DOT FLEET ADMIN
Note: This page may be copied if additional vehicles need to be added to the permit. Any additional sheets
attached must provide the vehicle and equipment information in the same format as above.
3000.321-006(R ers) Page 3 of 7
AUTHORIZED EMERGENCY VEHICLE PERMIT
APPLICATION w.
2 Vehicle Information: List all vehicles intended to be used as authorized emergency vehicles. For each
vehicle, provide all vehicle and emergency equipment information as outlined below, Prior approval must be
given before utilizing a new vehicle or a vehicle with equipment installed other than what is authorized under
the current permit for that vehicle. Proof of insurance for each vehicle must be attached pursuant to WAC
204:36-030. If providing funeral escorts, proof of commercial insurance in Washington State or business
use exemption must be provided pursuant to WAC 204-36-040.
VEHICLE INFORMATION EMERGENCY EQUIPMENT INFORMATION
YEAR LICENSE NO.� INSTALLED MAKE MODEL
2015 A7802C J ® SIREN �r
MAKE MODEL ® LAMP(S)(location/colors)
FORD F250 REAR/RED
VIN FRONT/RED
IFD7X2A65FEC16488
REGISTERED OWNER ❑OTHER EQUIPMENT:
KING COUNTY DOT FLEET ADMIN
VEHICLE INFORMATION EMERGENCY EQUIPMENT INFORMATION
YEAR LICENSE NO, INSTALLED MAKE MODEL
2015 A7801C ✓ ®SIREN
MAKE MODEL ®LAMP(S) (location/colors)
FORD F250 REAR/RED
2• VIN FRONT/RED
I F D7X2A63 FEC 164 87
REGISTERED OWNER ❑OTHER EQUIPMENT:
KING COUNTY DOT FLEET ADMIN
VEHICLE INFORMATION EMERGENCY EQUIPMENT INFORMATION
YEAR LICENSE NO. INSTALLED MAKE MODEL
2015 A7800C ® SIREN
MAKE MODEL ® LAMP(S) (location/colors)
FORD F250 REAR/RED
3• VIN FRONT/RED
I FD7X2A67FEC 16489
REGISTERED OWNER ❑OTHER EQUIPMENT:
KING COUNTY DOT FLEET ADMIN
VEHICLE INFORMATION EMERGENCY EQUIPMENT INFORMATION
YEAR LICENSE NO INSTALLED MAKE MODEL
2016 B3074C ®SIREN
MAKE MODEL ®LAMP(S) (location/colors)
FORD F250 REAR/RED
4•,VIN FRONT/RED
1FD7X2A68GEB55056
REGISTERED OWNER ] OTHER EQUIPMENT
KING COUNTY DOT FLEET ADMIN
Note: This page may be copied if additional vehicles need to be added to the permit. Any additional sheets
attached must provide the vehicle and equipment information in the same format as above.
3000-323-006(R Oil s) Page 3 of 7
AUTHORIZED EMERGENCY VEHICLE PERMIT !,t n:
APPLICATION W'"i1r
2 Vehicle Information: List all vehicles intended to be used as authorized emergency vehicles. For each
vehicle, provide all vehicle and emergency equipment information as outlined below. Prior approval must be
given before utilizing a new vehicle or a vehicle with equipment installed other than what is authorized under
the current permit for that vehicle. Proof of insurance for each vehicle must be attached pursuant to WAC
20n-3(5-030. If providing funeral escorts, proof of commercial insurance in Washington State or business
use exemption must be provided pursuant to WAC 204-36-040.
VEHICLE INFORMATION EMERGENCY EQUIPMENT INFORMATION
YEAR LICENSE NO, INSTALLED MAKE MODEL
12015 B3758C ✓ ® SIREN
MAKE MODEL ® LAMP(S) (location/colors)
FORD F250 REAR/RED
� VIN FRONT /RED
I FD7X2A60GEC25178
REGISTERED OWNER ❑ OTHER EQUIPMENT:
KING COUNTY DOT FLEET ADMIN
VEHICLE INFORMATION EMERGENCY EQUIPMENT INFORMATION
YEAR LICENSE NO, INSTALLED MAKE MODEL
2015 B3759C ✓ ❑ SIREN
MAKE MODEL [_ LAMP(S)(location/colors)
FORD F250 REAR/RED
Z•1 VIN FRONT/RED
' 1FD7X2B64GEC25179
f REGISTERED OWNER ❑OTHER EQUIPMENT:
KING COUNTY DOT FLEET ADMIN
VEHICLE INFORMATION EMERGENCY EQUIPMENT INFORMATION
YEAR LICENSE NO. INSTALLED MAKE MODEL
2019 C7506C v ®SIREN
MAKE MODEL ® LAMP(S)(location/colors)
FORD F250 REARMED
3• VIN FRONT/RED
I FD7X2B6XKEF56258
REGISTERED OWNER ❑OTHER EQUIPMENT
KING COUNTY DOT FLEET ADMIN
VEHICLE INFORMATION EMERGENCY EQUIPMENT INFORMATION
YEAR LICENSE NO. INSTALLED MAKE MODEL
❑ SIREN
MAKE MODEL ❑ LAMP(S)(location/colors)
4• VIN
REGISTERED OWNER ❑OTHER EQUIPMENT:
KING COUNTY DOT FLEET ADMIN P
Note: This page may be copied if additional vehicles need to be added to the permit. Any additional sheets
attached must provide the vehicle and equipment information in the same format as above.
3000-323-006(a 8/15) Page 3 of 7
AUTHORIZED EMERGENCY VEHICLE PERMIT w 11 t Q '
APPLICATION w3ir
3. Operators: Please list all drivers that will be authorized to operate the vehicle(s) listed in this application
and indicate whether or not the operator/driver is new since your last application by placing an X in the
"New?"column; otherwise, leave this column blank. No drivers should be listed unless they have been
approved. Per WAC 204-36-040, all operators involved in traffic control must be a Washington State
certified flagger, and carry their certified flagger card at all times.
Name Driver's License Number Flagger C
by L. WDL573P4J73B V Y
Goldstone, Marcy K. GOLDSMK180CW v Y
Green, Chelsea J. GREENCJ310ME V T Y
Nickelson, Steve K. NICKESK269JD V Y
Fowler, Diana M. WDLBSTZF823B li Y
Reyes, Silvia WDL6R854883B V Y
3000-323-006(R 8/15) Page 4 of 7
AUTHORIZED EMERGENCY VEHICLE PERMIT W
APPLICATION
4. Geographic Area: Indicate which types of roads and which specific geographic area(s)the authorized
emergency vehicles will be used. Certification from each jurisdiction is required under WAC 204-36-030.
Certification is covered in section 6 of this application.
Beaux Arts, Bellevue,Black Diamond,Carnation, Clyde Hill,
Covington, Duvall, Enumclaw, Issaquah, Kenmore, Kent, Lake
Forest Park, Maple Valley, Mercer Island,Newcastle,North Bend,
Redmond, Sammamish, Snoqualmie, SeaTac, Shoreline,Tukwila,
® City Streets (list all cities) Woodinville and Yarrow Point
( County Roads (list all counties) King ounty
® State Routes/Interstates (list all state routes, interstates, and counties)
I-5, I-90, I-405, SR 18, SR 169 SR 906 SR 164, SR 410 and SR 167
King Count
5. Permit Validation:
I certify(or declare) under penalty of perjury under the laws of the state of Washington that the foregoing is
true and correct to the best of my knowledge, information, and belief, and that:
a. All of the information given in this application is correct to the best of my knowledge and provided in its
full format to the undersigned chief law enforcement officer or fire chief(if the vehicle is to be used for
firefighting purposes)of each primary jurisdiction in which the vehicles are to be used as authorized
emergency vehicle(s).
b. None of the drivers, to the best of my knowledge, in the last year, have been convicted of, nor served
any sentences or periods of probation for any felonies, nor arrested and convicted of a drug or alcohol
violation or illegal use or possession of drugs, nor been required to register as a sex offender.
c. Only the vehicle(s)and equipment listed in this application will be used as outlined in this application,
and that only the operators listed under this permit will drive the vehicle(s).
As the primary holder or executive officer in charge of overseeing this permit, I understand that if the permit
is issued, it is my responsibility to ensure:
a. No driver listed in this permit uses the vehicle for any purpose not authorized under this permit unless
all emergency equipment is removed or covered.
b. No driver other than those listed under this approved permit operates the vehicle(s) listed unless all
emergency equipment is removed or covered. If I wish to add a new driver or vehicle to this permit, I
must receive prior approval before they are authorized under this permit.
c. The driver must exercise due care and caution and must obey all traffic laws.
I understand that the inappropriate or misuse of authorized emergency vehicles may result in criminal or civil
liability as well as cancellation of this permit as outlined under chapter 204-36 WAC.
In addition, I understand that it is my responsibility to ensure that a copy of this permit listing all approved
drivers and geographic areas authorized, as well as a copy of the vehicle permit authorizing emergency
equipment is present in each vehicle at all times and must be presented to law enforcement, if requested.
Signature Title
(CHIEF EXECUTIVE OFFICER)
Name Date
(TYPE OR PRINT)
3000-323-006(R 8115) Page 5 of 7
AUTHORIZED EMERGENCY VEHICLE PERMIT !
APPLICATION
3000-323-006(N e115) Page 6 of 7
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STATE OFVMSMJNGioN
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CERTIFICATE OF SELF-INSURANCE
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30 KING COUNTY VEHICLE DRIVER'S OPERATING MANUAL lREV41161
^AUTHORIZED EMERGENCY VEHICLE PERMIT UW
(APPLICATION
6. cert[ficatlon: Tills application for an Authorized Emergency Vehicle Permit will not be accepted unless
CERTIFIED by the chief law enforcement officer or fire chief(If the vehicle Is to be used for firefighting
purposes)of each primary Jurisdictlon in which[he vehlclo(s)are to be used as authorized emergency
vehicles(see part A at this applicatlon). If the application is made by the chief of a law enforcement agency
or fire departniont.It must be GERTIRED by(he head of(lie political sub-divlslon. The certification must
Include the folfowing language:
"I hereby certify that I have reviewed[his entire application; that I am aware that the applicant Intends to use
the vehlcle(s)and emergency equipment listed in{part 2 of this application,for the specific purposes Ifsled In
part 1 of this application;that a need exists In my jurisdiction for the listed vehicle(s)to be used as
authorized emergency vehicles and that the appllcant has the appropriate authority as described in part 1 of
this application to operate such equipment;and I know of no reason why this application should be denied."
Please type or print:,,
e/Dato Title
Name
(PleeeaPAnll l �'`�4 KAI&H,flurisdiction _ k I�l
Phone {Zoe-)- z S S S _ E-Mail
Restrictions
Signature Date 04/23/21 Title Sheriff —
Name —�-
(PleeeaPinl) __.Mitzi G.Johanknecht — Jurisdiction
('hone �20s 263-2555 E-Mail
Restrictions -
Signature Date _ Title
Name
(PleeeePAN) Jurisdiction — —
Phone ( E-Mail _
Restrictions
Signature Date Title
Name
(r9eaeaPAnl) _-_- Jurisdiction
Phone (_..__).._..__.--..----.---- __-- E-Mail _
Restrictions
Signature Date Tllle
Name
(PleavaPrinr, --- __--- Jurisdiction --
Phone ( — _ E-Mail
Restrictions
Signature - --- -- - Date Title -
Name
(Plea"PIN) - -- - Jurisdiction --- _
Phone ( E-Mail
Restrictions
Note: This page may be copled If additional certifications need to be added to the permit. Any additional
sheets attached must provide the certification information in the same format as above.
Page 7 of 7
AUTHORIZED EMERGENCY VEHICLE PERMIT i
(APPLICATION
B. C9rtffloa Ifni v This application far an AuIIiorized Eniergaicy Vvlrlcle PormII wBi n a t be accepted an%as
CERTiFIF❑by the chief Inw onforcomanI ofttoer or fire ohlef tff the vohlele to to be used for nrolightina
purposes)of oacti primnry irlrlsfllmlon GI Which Ilia vohirin(a)ern to he uRed na authorized siriargeney
volilclos(goo part p of this applioation). if the eppliastiert in mo(fu by the cldaf of o luw rinforcament agoltcy
or firs dapodnxrnt,It must be CERTIFIED by the ltRad of the polll(csl sub•dMelon. The anrtlfinnilon must
Include the fallowing Initguana,
"i hereby certify that I have roviewed this entire apprtloullon;that I am aware that ilia applioant Intends to use
the vahlcle(s)rand emergency equipment fisted In part 7.of Ihls spplicatteii.for the spaclflo purposes listed In
part'I of this appitcatlori;that a nsed exlsta In my)tirisdlclfon for the tinted vaNcla(a)to be used as
authorized emergency vehicles and that the applicant has the appropriate authorlty as desarlbed In part t of
this reppl feat lan to apa?ato Rairh equlpmor1;and I krlow of no few on why this appIIo ali6n ehoutd be daniad."
Please type or print,
14
Slgnatum/ r� �Qata 9Izt/� Tite ,1��/�/f�
Name 77.� 447W'Milodi0tfon (�t N G FC7(.WT(Pleus0AN1 i_ r ... --
Phone .Q.��.,�_ 4 .-z S V E-Mail
Restrictions ,2Aj t�,-
Signature _ 1'f Date jfi Title
Name
(Praocwnu _ � lurifscllctiac� 'Tv -r 1
E-Mall jLe4Lny, _ 4,1: , u• r + `
Restrictions ram, 1
Signature _ _ „ Dale Title
Name
IvdmaPrnil Jurisdiction
Phone (.. �- - — - — E-Mail -
Restrictions -
Signature Date Title
Name
(PlsriuPA(a) _.- --- - - --. -. ... . Jurisdiction
Phone (. ) ----- E-Mail -
Restrictions
Signature Date _ Title
Name
(PpONININr ------ - ---...--- ------ - Jurlsdlctlon
Phone t .).. - - - - - - E-Mail _-
f�r�strletions
Signature _ Date Title
Name
(PIondvdell Jurisdiction — —
Phone ( ) E-Mail
Restrictions
Note: This pane may be copied If additional cerfiflastions need to be added to the permit. Any additional
sheate attached must provide the certilloallon Information in the some format as above,
auooas3 oee(R Ol1B) Page 7 of 7
e
AUTHORIZED EMERGENCY VEHICLE PERMIT
APPLICATION
6. Certification: This appffeallon for an Authorized Emergency Vehicle Permli will not be accepted unless
CERTIFIED by the chief faw, enforcement officer or Ilre chief(if Ilia vehicle Is to to used for firefighting
- purposes)of each primary Jurisdiction In which the vehicle(s)are to he used as authorized ome►goncy
vehiclas(see part 4 of(his application). If Ilia application Is made by the chlal of a raw enforcement agency
or fire department,it niusl be CERTIFIED by the head of the political sub-dlvlelon. The certification must
Include the roilowing language:
"I hereby certify that I have reviewed this entire application;that I am aware that the applicant intends to use
the vehicle(B)and emargency equipment listed In part 2 of this application.for Iha specific purposes listed In
part 7 of this application;that a need exists In my jurisdictlan for Iha listed vehicie(s)to be used as
authorized ernergoncy vahlcles and that(he app)Icant has the appropriate authority as described In part 1 of
this application to operate such equipment;and I know of no reason why this eppllcallon should be denied."
Please type or print
5lgnature11, Date 9/�r/L Title 1W.Qfl Awf
Na wnPAW ) !W► H f Turlediction 141 N G e-eQ T y
Phone fir, _!fir _A_z-9 C-C E-Mall
Restrictions *4 e
Signature Date o -F r . Title
Name
(MARG a,i) �- Carr Jurisdiction L' T
Phone w ysi-y E-Mail
Restrictions
Signature Date Title
Name
mansearru) Jurisdiction _
Phone (--) — E-Mail
Restrictions - -
Signature __ Date _ _ Title
Name(RomPArAl Jurisdiction _ —
Phone ) --T .._ E-Mail - -
Restrictions J
Signature Date Title
Name --- �_ - - --
(FI�6i.nwl Jurisdiction
Phone E-Mail - —
Restrictions
Signature Date Title
Name --.--- ----.._..- -
(Prwnov") Jurisdiction
Phone -- __ - E-Mall - - -
Restrictions
Note: This page may be copied If additional certifications need to be added to the permit. Any additional
sheets attached must provide the certification Information in the same format as above.
now-223•ow(q oils)y.-- - T Ra ige 7of7
AUTHORIZED EMERGENCY VEHICLE PERMIT ,
!APPLICATION
6. Certification; This application for an Authorized Emergency vehicle Permit will not be accepted untesa
CERTIFIED by the chlot law enforcement officer or fire chlef(If the vehleie Is to be used For firefighting
purposes)ur each primary IurlsdlcI[on in which the vehiele(s)are to be used as authorized emergency
vehlclea(see part A of this applicellon). if the appiloatlon Is made by the chief of a law enforcement agency
or lire department,it must be CERTIFIED by the tread of the political sub•divislon. The ec rilffcallon must
include the following language,
"l hereby certify that I have revlowea IhIs entire application;that I am aware tha(the appf Ica nt Intends to use
the vehicla(s)and emergency equipment listed In part 2 of this application,for the epecillo purposes listed In
part 7 of Ill Ia apptloatton;that a need exists In my Iuriadictlon for the Ifsled vehicles)to be used as
authorized emergency vehicles and than the applicant has the appropriate authority as described In part 1 of
this application to operate such equipmenl;and I know of no reason why this application should be denied"
Please type or print
S nature ��q/r<T/Ld�q
15 Date Title
Name Al(r(�.wanm► �_ y?(r � � fTuiditi IG� - --
Phone QLt 4 .-z S S E-Mall
Restrictions ,.r - Y Y -
Signature Date I t; lr ICI Title �k j,t e,
Name T
I 1 b I r _ Jurisdiction
Phone t• C` E-Mail
Restrictions
Signature Dale Title
Name --
(pbna vrnu Jurisdiction
Phone ._.� �.� ��-- E-Mail
Restrictions
Signature `— Date Title
Name
(Plea""All Jurisdiction
Phone (_- ---- - ... -- E-Mail
Restrictions -
Signature _ Date Title
Name -
(Prnawrbinn _�_.. Jurisdiction
Phone �_ J - E Mall
Restrictions
Signature - _ T Date Title
Name --- - --
�ra.�,,artM► - Jurisdiction
Phone ( E-Mail
Restrictions
Note: This page maybe copied if additional certifications need to be added to the permit. Any additional
sheets attached must provide the certification Information in the some format as above.
3000•32340(nNIe) - _._.._. ---.-----•-- -•-- Page 7of7
AUTHORIZED EMERGENCY VEHICLE PERMIT "
!APPLICATION
4. Certification: This application for an Authorized Emergency Vehicle Permit will not be accepted unless
CERTIFIED by the chlof law enforcement officer or fire chief Tit the vehicle is to be used for firef lghting
purposes)of each primary f urisdfcllon In which the vehlcle(s)are to be used as authorized emergency
vehicles(see part A of this application). If the application is made by the chlaf of a law enforcement agency
or lire department.it must be CERTIFIED by the head of the political suh•dtv[slon. The carllflcgllon must
Include the following language:
01 hereby cetllty that I have reviewed this entire application;that I am aware that the applicant Intends to use
the vehlcle(e)and emergency equipment IN led In part 2 of this application,for[he specific purposes listed In
part 1 of this applicafFan;that a need exisle In my iurledlcl[on for the listed vehlcle(s)to be used as
authorized amorgency vehicles and that I h a appllcant has the appropriate authority as described In part 1 of
this application to operate such equipment;and 1 know of no reason why this applleatlon should be denied."
Please type or print:
Signature
JGI �Data��z r/y Title J'/f�t/ff
(Pru
Name �1 , -�-6 �,AZH f Turlsdicticn k l Af 6 roU�7`Y
..mnn
Phone 2p ze. S—zs:s-_C E-Mall
Restrictions ",d C -
Signature _ :..- Date to fs M Title CehfF
Name - -- --
(weo Mo KY L-C L. V y 4-tn!(, Jurisdiction CA.yDCt- WI u- PPO u"
Phone 1 N -j E-Mail ,
Restrictions
Signature _ Date Title
Nam" _ Jurlsdiction
Phone _(�� E-Mail -
Restrictions -- _
Signature Date Title _
(Plulorml) Jurisdiction W
Phone 4_-_ E-Mail
Restrictions
Signature _ _ Date Title
Name
► Jurisdiction
Phone t E-Mail
Restrictlons
Signature _ Date Title
Name
n Jurisdiction -
Phone ( E-Mall
Restrictions - - ----
Note: This page may be copied If edditlonai carllRcations need to he added to the permit. Any additional
Sheets attached must provide the certification Inrormatlon in the some format as above.
�aooar�aoetael�et --�""— T
Page 7 017
AUTHORIZED EMERGENCY VEHICLE PERMIT
APPLICATION
S. Cerilficallow This application for an Authorized Emergency Vehicle Permit will not be accepted unless
CERTIFIIED by the chief law enforcement officer or fire chief of the Yoh late Is to ba u 9 a d for firefighting
purposes)of each primary lurlsdlctlon In which the vehicle(a)are to be used a aiul11aOzod emergency
vehicles{see part A of this application)]. It the application is made by the chlef of a law enforcement agency
or lire department,it must be CERTI&D by Ilia head of the political sub•divlslon. The cerllflcallon must
Include the fallowing language:
'I horeby certify that I have reviewed this an tire application;that I am awe re the It the applloanI Intends to use
the vahlcte(s)and emergency equipment listed In part 2 of this application,for the specific purposes Ilated In
part 9 of this application;that a naad exlsts in my JurlsdtoUon far the listed veh(Wa(s)to be used as
authorized Gill arganoy vehicles and that the appllcant has Ilia appropriate authority as described in part 1 of
this application to operate such equipment:and I know of no reason why this application should be denied,"
Please type or print- _
0g/ /zd��'
Slgnature Date Title
Name
(PIN PM11 It't L__ •_ N,l�KN�1f'Turisdiction 1<t N G__CgQj�vTh'
Phone Q or, x e. :3--z r t_C E-Mail
Restrictions r►
Signature Date _2 yTitle �<e'621_2_p
Name `T
(MA10 RI11 ,Q �{ Jurisdiction
Phone 'a5) 7�5 "!J` _ E-Mail
Restrictions __. ��
Signature _ Dale Title
Name
(PlemPrM Jurisdiction
Phone S ) _ E-Mail
Restrictions
Signature Date Title
Namit - ' Jurisdiction- - - -
Phone _iTY E-Mail - --
Restrictions
Signature Date Title
Name - - — - .W� - -
(P1e.1.FIND - Jurisdiction
Phone _ } E-Mail
Restrictions
Signature _ Date Title
Name
(FilmM) —_ Jurisdiction
Phone � .._ - -..... - - ---. ----
} E-Mail
Restrictlons
Note: This page may be copied If additional certifications need to be added to the permit. Any additional
sheets attached must provide the certification information in the some format as above.
........ ^---- -- _...
aoao'ar�'ooa(na+t°r Page 7 of 7
AUTHORIZED EMERGENCY VEHICLE PERMIT
APPLICATION ,
8. Certification: TWO application for an Authorized Emergency Vehicle Permit will not be accepted unless
CERTIFIED by the chief law enforcement officer or We chief(it the vehicle Is to be used for firefighting
purposes)of each primary jurisdiction In which the vehlnle[a]are to be used as suttsmirod emotgaricy
vehicles(soo part A of this eppllCaRonl, If Ihs application Is made by the chief of a law enforcement agency
or fire department,it must be CERTIFIED by the head of the 00I111cal sub-divlslon. The certlfloallon must
include tiro following language:
"I hereby certify that I have reviewed this entire application;that I am aware that the applicant Intends to use
the vehicle(a)and emergency equipment listed in part 2 of this application,for the specfiic purposes listed In
part 4 of this application;that a need exists In my iufisdMion for the listed vohicla(s)to tsa used as
aulhorixed emergency vehicles and that tha applicant has tha appropriate authority as desarlbad in part t of
this appI[catior}to operate such oqulpman1:and I know of no reason why Ihis appllcatlon should be denied."
Please type or print: /
Signature pate Title
Name
IPIew Hill) /�.«2.l__ K► R1 iarisdiction l�rn! r N_Ty
Phone (Zoe) e-G Z- S V C E-Mail
Restrictions AAW -
Signature Dated Iqe ❑ rQ� �r d"
Name rC
(PI saftN) p 9,tafatcr — _ _ Jurisdiction AEn�ccrrte � IQ/ire _
Phone _(:lop _Sz5.3S,OS' E-Mailb4ge UU/0-e..r6 Av!wLv k�• .wf•
Restrictions
Signature Date Title
Name ---- - - - -- ---
(Freels Prnl) . -_-__ Jurisdiction
Phone ( _.�.. . _ E-Mail
Restrictions
Signature Date Title
Name
(PleeeePAnl) _ Jurisdiction
Phone (_..,..._). E-Mail
Restrictions
Signature Date _ Title
Name Jurisdiction(PlaelePAnl) -.-. - .._.
Phone ) E-Mail -
Restrictions
Signature Date Title
Name t � Jurisdiction
Phone _C - 2 -- - E-Mall -
Restrlotions -
Note: This page maybe copied if additional certifications need to be added to the permit, Any addlllonal
sheets attached must provide the certification Information in the same format as above.
3000•323-006(Rolls) Page 7 of 7
AUTHORIZED EMERGENCY VEHICLE PERMIT
'APPLICATION
5, Certification: This application for an Authorized Emergency Vehicla Parmltwill not ba accepted unless
CERTIFIED by the chief law enforcement officer or fire chief(If the vehicle Is to be used for firefighting
Purposes)of each primary jurisdiction In which the vehicle(s)are to be used as authorized emergency
vehicles(see par!A of this application). If the application is made by the chief of a law enforcement agency
or fire department,it must be CERTIFIED by the hand of the political sub•divlslon. The certification must
include the following language;
"t hereby certify that I have reviewed this entire application;that I am aware that the applicant Intends to use
the vehlcla(s)and emergency equipment listed In part 2 of this application,for the specific purposes listed In
part 9 of(his application;that a need exists In my Jurlsdiellon for the listed vehlcle(s)to be used as
authorized emergency vehicles and that the applicant has the appropriate authedly as described In part 3 of
this application to operate such equipment;and I know of no reason why this appllcatlon should be denlad."
Please type or print:
Signature Iflo_ Da-#o-
7��r/L Tic _P/ -0 /,
Name
. -
(PI•M t9 Al t 1 L . �Ao,4 XPEf Mrisdiction 11N G e"C Ty
Phone
G s Z s s S E-Mail
Restrictionsp,,� --F
Signature Date Title
Name I tI
(Pwkep" -S ., Jurisdiction C r r � tA�►se�!.�_�
Phone _C±&Io Q3~I - 3 0 E-Mail 5ca-,~r`� e.a�.sr.r.,� .s
Restrictions �p,,,�
Signature Date Title
Name
(Plan"Rina _ Jurisdiction
Phone ( -- - E-Mail -
Restrictions -
Signature _ Date Title
Name
Jurisdiction
Phone _�....__� E-Mail — - -
Restrictions --
Signature Date Title
Name
tP�.ee Rim) Jurisdiction
Phone _ E-Mail -
Restricllons - - _—
Signature Date Title
Name —- --
(Nes as _ _ Jurisdiction
Phone ( E-Mail - -
Restrictions
Note: This page maybe copied if additional certifications need to be added to the permit. Any additlonal
sheets attached must provide the certification information in the same format as above.
3000�3230M(R 61t5) __.._..� Page 7 of 7
AUTHORIZED EMERGENCY VEHICLE PERMIT
APPLICATION _--
8. Corliffcallon: This application far an Authorized Emergency Vehlcle Permit will not be accepted unlese
0ERTIFIED by the chief law enforcement officer cr fire chief(If the vab Iola is to be uaad for firafIgh tin g
purpaaaa)of each primary jurladiolIon In which the voh let e(s)are to bu uaed as aulhcrlr-ed arnergsncy
vehicles(see part A of this application). If the application Is mnda by the chlaf of a law enforcement regency
or We depsriment,It mull be CERTIFIED by the hear[of the political sub•divielon. The certlflcatlon must
Include the folfowfng Innpuege:
"I hereby certify that I have reviewed Ihla entire application;that i am aware that the applicant Intends to use
the vshfols(e)and emergency equlpmant lialed In pert 2 of this appllcnllon,for the spaciflo purposes Ilstsd In
part t of this sppVcatlon;Iha(a need exiata In my Jurladictlon for the listed vehicle(s)to be used as
outhorlxed emergency vehicles and that the applicant has the appropriate authority as described In part 1 of
this application to operate ouch equlpment;and I know of no reason why this application should be dented."
Please type or print: _
Signature Qate FittTe XIIQt/fF
Name
(PkMftwl 4. n vQ.lf'IfTurlediction k/N 6 r" 7-7
Phone Div& E-Mail
Restrictions Arks
Signature Date / t)1-1 y Title _GIJEr
Name �
rpr«..wma Jurisdiction ¢ Cr!_
Phone (p�3) `g- -_S�lo� E-Mall a i . A
Restrictions
Signature Data 7�► (Title �ll��
W*MFMo Ar0444- Jurisdictlon L< ri -
Phone (2 ID BSr+ - Oo E-Mail & _94A W 4 (4a__. ),v
Restrictions
Signature _— Date - -�� Title ---
Name
,phmpdd) Jurisdiction
Phone ,S_._-) — - E-Mail
Restrictions
Signature _ _ Date Title
Name
(Pr....pdnr) -- -.-..- — Jurisdiction --
Phone ( ^� E-Mail
Restflctlons
Signature Date Title
Nam(FUMPOW) - Jurisdiction - - --
Phone ( ) E-Mall
Restrictions
Note: This page maybe copied If addltlonal ceftifloatione need tube added to the permit. Any addlllonal
sheate attached must provide the certification Information in the same format as above.
aauoata oosptate) Page 7of 7
AUTHORIZED EMERGENCY VEHICLE PERMIT
!APPLICATION
6. Certificattion: This application for on Authorized Emergency Vehicle Permit will not be accepted unless
CERTIFIED by lite chlof law enforcement officer or flro chiei(If the vahlcle is to be used for nrattghting
pUrposes)of each printery Jurkdlcllon In which the vehlclo(s)are to be usod as authorireri arnarQency
vehicles tsoo part A of this appticallony. If the appllentlon is made by the ohlef of a taw unforcomont agency
or fire department.it must be CCR7li'iED by the head of the political sub-division. The cadiltcnpon must
Include thfl following language:
"I hereby ce(pfy that I have reviewed Ihls entire applicattort;that I am aware that Ihn applicant I mends to use
tho vahlcte(s)and emergency equipment listed in port 2 of this;application.for the specific purposes listed In
Part 1 of this applicatlnrr Iha(a need exists In my Jtsrlsdictlon for the listed vehlcle(s)to be used as
authorized emergency vehicles and that the app)lcant has the appropriate authority as described in past t of
this application to opera Ia silch equlpment;and I know of no ran son why Chia application should be denied:"
Please type or print-
Signature 09Iz r/
_ Data Title f�feZ/FT
Name � —
(PlooIoP O /1 iT7 f _._._...�4�_�q X1vtZ fTurlediction F�i t4 G rp(1NT
PZne (Z G..}...?.3 ��- S 5 - E-Mall -- = -
Restrictionsa "
Signature _ Date A&2:eV Title _P
Name
(p(eo.aP,lnu Mr[ - - — _..._ Jurisdiction G f t '�c3r P 4rz P,b,
Phone S" .).9�7- 5'1_— __.... E-Mall rJroEt,F .Cru
Restrictions
Signature / Date Title
Name
(Ple"86Pma -. Jurisdiction
Phone ...__.)._.... - E-Mail _
Restrictions
Signature Date Title
Name - -.. _.. .
(Plew.pA ll _ _.. .. Jurisdiction -
Phone [_..W }.--- - _�.. S-Mail
Restrictions
Signature _ Date Title
Name Jurisdiction
(Plum Halt _r ..
Phone �( ) E-Mail
Restrictions
Signature - Date Title
Name
(PledwW) Jurisdiction
Phone ( } E-Mall
Restrictions
Note: This page may be copied If additional certifications need to be added to the permit. Any addlllonal
shoots attached must provide the certification information in the some format es above.
0000.323 ode(11 Oil 51 Page 7 of 7
AUTHORIZED EMERGENCY VEHICLE PERMIT or
!APPLICATION
0. certiffcatlon: "I'his application tar an Aulhorfzed Emergency Vehicle Permit Wit not be accapled unless
— CERTIFIED by the chlof law enforcement officer or fire chief(If lho vehicle to to be used for firefighting
purposes)of each prlmary lufisdlctlon In which the vaNcle(s)are to bo used as outhorixed emergency
vehtcles(see part 4 of this application). If the oppllcallon Is made by the chlef of a haw enforcement agency
or fire depadment,it must be CFRTIFIED by the hood of the political sub-dlulelon. The cartiflcnllon must
inciuda the fAnwing language
01 hereby certify that I have reviewed this entire application;that I am aware that the applicant Intends to use
the vahlcls(s)and emergency equipment listed In part 2 of this application,for the specifle purposes listed In
part 1 of Ibis application;thal a need exists In my Jurisdiction for the Killed vahlrlu(s)to be used as
aulhodzed emergency vehicles and that the appileent has the appropriate authority as described In part 1 of
We applloallan to operate such equipment;and I know of no reason why this application should be darted."
Please type or print: _
r�qr/zd�9
Signature ��
Date _ Title Jr/I!Qf/f/F
me
(N►ras " &F 1 4��K-&4 A aHITurlsdiclion l<<(! G roQjv7-,Y
Phone (be %4 3. Z.s V-C E-Mail
Restrictions —
Signature -- Date io Z2//, Title �030
N
Zli EA_. Ss�wC� Jurisdiction Mmwt lst�0 _
Phone -a! I t E-Mail Gb. l(o'.Vgdg ►e Mot-,es-5 aref
Restrictions o r
Signature Date Title
Name
(Maup") Jurisdiction
Phone _ )_ E-Mail
Restrictions
Signature Date Title
Name --- Jurisdiction - -
Phone ( } W — E-Mall
Restrictlons
Signature Date Title
Name
(1440"MWI Jurisdiction
Phone - ( ) E-Mail T
Routrlctions
Signature u_ Date Title
Name
(FIN" ") _ Jurisdiction
Phone ( --a - E-Mall _-— -- - -
Restrictions
Note: This page maybe copied If addWanal cerdficattone need to be added to the permit. Any addillonal
sheets attached must provide the certification Information In the some format as above.
aam•aracoe(nene) � �- __w ._._-�__ .---..�._ Page TofT
AUTHORIZED EMERGENCY VEHICLE PERMIT T _
APPLICATIONJW
S. Contlffaallow This application for an Auttusrized Emergency Vatitcla Permit will not 13e accepted unless
CERTIFIED by the chief lave enforcement officer or lire chief(if ilia vehicle Is to be used for riraltghting
Purposes)of each primary)urisdiction Ill wllich the vahicle(s)are to be used as aulliorized emergency
vahiclos(Sao part R of this application). It the application Ea made by ttie chin of a law enforcement agency
or lire department,it must be CE.RTIF 1E;D by ilia tread of Ilia political sub•dlvislnn. Tho carttilcailon must
Include the following ldngilage:
"f hereby celfify that I have reviewed this entire application;that I am aware that the applicant Intends to use
Ilia vetilcle(s)and eniargency equiprnant listed In part 2 of this application,for the specific purposes listed In
part 1 of this application:that a need exists in my iurisdIctlon for the lieted vehicle(s)to be used as
authorized emergency vehicles and that Itie applicant has the appropriate authority as described to part 1 of
this application to op are to such equlpmen1;and I know of no Beason wily Ihle application should be danced."
Please type or print:
Slgnature ,�C.� ° I ����
�� bate Title {BtI��
Name
1 NaHYTurisdiction A� N G
(Pleew PdN /t1,(1��- ��I? ,�� I
Phone
o E-Mail
Restrictions -
Sigtlature • ,C Date ��Z/ .9 Title C'1uAie L
Phone "e
Neme �f/1 --- _
(Pl�aie Pflrll) P/1L Jurisdiction Slva `r�irr/
---��-__.____.._ - _---
t3 3 3 3 __.. E-Mall O Oh(y,p?$$_.�a3, ro .Ir�r�6.w� .30✓
Restrictions1��/,C:f- -
Signature Date Title
Name
1Plenie Prii) _ _ _ Jurisdiction
Phone L ) E-Mail __..... ---_.
Restrictions -------� ---
Signature Date Title
Name --- --
(Please Prtnl) Jurisdiction
Phone }_..__. E-Mail
Restrictions
Signature Date Title
Name
(P1ee1ePrIall -__ . -_.- Jurisdiction _
Phone ( } E-Mail -- -
Restrictions
Signature Date Title
Name _----- - - -----------. -
(PleaeaMAI) —_ Jurisdiction
Phone ( } -— E-Mail
Restrictions
Note: This page may be copied If additional certifications need to be added to the permit, Any additional
sheets attached must provide the certification information in the some format as above,
0000.023 000(R 0116) .-.
Page 7 of 7
AUTHORIZED EMERGENCY VEHICLE PERMIT
,APPLICATION
S. Certification: This application for an Authorized Emergency Vehicle Permit will not be accepted unless
CERTIFIED by the chief law enforcement officer or fire chief(if the vehicle is to be used for firefighting
purposes)of each primary jurisdiction In which the vehlcle(s)are to be used as authorized emergency
vehicles(see part A of this application). If the application is made by the chief of a law enforcement agency
or fire department, it must be CERTIFIES?by the head of the poll[Ica]sub-divislon. The certification must
Include the following language:
"I hereby certify that I have reviewed this entire application; that I am aware that the applicant Intends to use
the vehicle(s)and emergency equipment listed in part 2 of this application,for the specific purposes listed In
part 1 of this application;that a need exists In my jurisdiction for the listed vehlcle(s)to be used as
authorized emergency vehicles and that the applicant has the appropriate authority as described in part 1 of
this application to operate such equipment;and I know of no reason why this application should be denied."
Please type or prin
t:
eDaie-f "Ar/te
Signature _ Title .jW.4Z/10--T
Name
(please NM) It'1 l�L -S0 +4 AA XkaH rTurisdiction le-r f4 e. T y
Phone _Q c6) u a —Z. S S S E-Mail
Restrictions , - —
Signature Date II- /3-,19Title C ff/
Name r _ _— ---- --
(Preee9P/iM) fT� � Jurisdiction
Phone L G - 2 C-Z�� E-Mail 1_c we at �1��.Gores
Restrictions
Signature Date Title
Name -
(Pieaee PrW) _ Jurisdiction
Phone ( E-Mail _
Restrictions
Signature Date Title
Name _ ........ �.�
(PfeaseRho Jurisdiction
Phone E-Mail
Restrictions
Signature Date Title
Name - .. ._ -
(Pleen RIM) Jurisdiction
Phone ( } E-Mail --
Restrictions _ ---{
Signature Date Title
Name
(PleawWN) _ Jurisdiction
Phone �_ - - E-Mail ---
Restrictions - - -- - _
Note: This page maybe copled If additional certifications need to be added to the permit. Any additional
sheets attached must provide the certification information in the some format as above.
3000.323 JR MS) W � Page 7 of 7
AUTHORIZED EMERGENCY VEHICLE PERMIT
-APPLICATION —
6, Certtftca;Ion: Th#s applleatioil for are Authorized Emergency Voliicls Permit will not be accepted unfees
CERMIEU by the chief law enforcement officer or lire shtof Rif the vehicle to to be u5cd for firefighting
purposes)of cacti printery Iurl:sdictlon In which the vehicle(s)are to be used as authorized emergency
vehiclos(see part A of this applfcaRony if the applfcetton Is made by the chlof of a law enforcement agency
or lira dapartmeni.It musl be CERTIFIED by(tie head of the political sub•divls(on. Tito cerllAr.Rilon must
Include the following language:
"I hereby certify Ihat I have reviowod I Ili s entire applioallen;that I am awe re that the appiicant Intends to use
tho vehfcle(a)and emergency equipment listed In part 2 of this applica[to n,for the specific purposes listed In
part I of this nppitcatlon;that ra need exists In my it+flsdtallon for the listed vehicla(s)to be used as
authorized emergency vehicles and that Iho appticonI has the appropriate authorlty as described in port t of
this appilcation to 0 pare to surh equipment;and I know of no reason why this appiIcatlon should tie denied."
Please type or prinL
Signature . rc Date"A r-/L Title
Name
�N► if'r urisdictson [SING N7,
Phone tz a.)...-t C. 3 Z. S; SS E-Mail
RestrictionsSignature' Date'.,'1,� ,� ,. Date f [I«L: Tltte r
Name
Jurisdiction
Phone r .,�_ ! E-Mall
Restrictions
Signature Date Title
Name —
tPr..l.PfiYtlr Jurisdiction
Phone E-Mail
Restrictions -^- -
Signature Date Title
Name
(Pl.... O) _ _ _-_ Airisdiction
Phone �( ) E-Mail
Restrictions --
Signature Date Title
Marne — _----- _..�.,...
tP1..1.Pr1nr, _ _ - Jurisdiction
Phone ( _� E-Mail
Restrictions
Signature Date Title
Name
IN"JON01) Jurisdiction
Phone y E-Mail
Restrictions
Note: This page maybe copied if additional certifications need to be added to the permit. Any additional
sheets attached must provide the certification information in the same format as above.
30ao,323 ooatnennr — - - -- - -- Page 7 of 7