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HomeMy WebLinkAboutMINUTES - 07261983 - ALL oh D I, NbTts AUL `/ Zb , 1 83 THE BOARD OF SUPERVISORS MET IN ALL ITS CAPACITIES PURSUANT TO ORDINANCE CODE SECTION 24-2.402 IN REGULAR SESSION TUESDAY JULY 26 , 1983 IN ROOM 107 COUNTY ADMINISTRATION BUILDING MARTINEZ , CALIFORNIA PRESENT: HONORABLE ROBERT I . SCHRODER, CHAIR, PRESIDING ; SUPERVISOR NANCY C. FAHDEN SUPERVISOR SUNNE W. MC PEAK SUPERVISOR TOM TORLAKSON ABSENT: SUPERVISOR TOM POWERS CLERK: J. R. Olsson, Represented by Geraldine Russell, Deputy Clerk 00 v' THE BOARD OF SUPERVISORS CONTRA COSTA COUNTY, CALIFORNIA Adopted this Resolution on July 26, 19839 by at least a four-fifths vote: AYES: Supervisors Fanden, McPeak, Torlakson, Schroder NOES: None ABSENT: Supervisor Powers RESOLUTION NO. 83/920 (Gov't. Code Sec. 25363) SUBJECT: Sale of Surplus Real Property Vacant Land at Southwest Corner of Livorna Road and Vernal Drive Project No. 0662-6U4283 Alamo Area The Board of Supervisors of Contra Costa County RESOLVES THAT: The Board by Resolution No. 83/801, dated July 7, 1983, determined that the County owned parcel described in the Notice of Public Land Sale attached thereto is surplus and that it is not needed for public use. The Notice of Public Land Sale set 11 :00 a.m. on July 15, 1983 at the property location, southwest corner of Livorna Road and Vernal Drive, as the time and place where oral bids would be received and considered for purchase of said property. The highest bid received for the property, in accordance with the terms and conditions of sale approved by this Board, was $79,000, by Chiao-Fu Chang and Sue Fay L. Chang, at which time the amount of $5,000 was deposited as an option-bid deposit to secure completion of the transaction. Said bid is hereby ACCEPTED and the Chairman of this Board is AUTHORIZED to execute a deed to the highest bidder for the property and cause the same to be delivered upon performance and compliance by the purchaser of all the terms and conditions set forth in the Notice of Public Land Sale. I hereby certify that this is a true and correcteopyof an act:oat:sken and entered on the rnlnutes of the Board of£upor0sorc on the date shown. ATTESTED: JUL jG, 1983 J.P.. OLSSON, COUNTY CLERK and ox officio Clerk of the Board By ,Deputy Orig. Dept.: Public Works (RP) cc: County Administrator Auditor-Controller Public Works Accounting Assessor RESOLUTION NO. 83/920 00 k.BO0726.t7 THE BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Adopted this Order on July 26, 1983 by the following vote: AYES: Supervisors Fanden, McPeak, Torlakson, Schroder NOES: None ABSENT: Supervisor Powers ABSTAIN: None SUBJECT: Consulting Services Agreement ) RESOLUTION NO. 83/9x1 with TJKM Transportation ) Consultant to prepare a ) traffic study for Marina Vista) in the Martinez area. Project) No. 0676-6P1984 ) IT TS BY THE BOARD ORDERED that the Public Works Director is AUTHORIZED to sign a Consulting Services Agreement with TJKM Transportation Consultant to prepare a traffic study evaluating traffic signal warrants, lane con- figuration and striping on Marina Vista between Shell Avenue and the most easterly I-680 ramps in the Martinez area. The full cost of $950 will be borne equally by County and City of Martinez. Payment limit may not be exceeded unless authorized by the Public Works Director. I hereby certify that this Is a true andcorrect copy of en action °aken and entered on the minutes of the Board of Supervisors on the date shown. ATTCEITED: JUL 2 61983 J.R. Ad.:'3SOVl, COUNTY CLERK and ex o'ifislo Cleric of the Board By 1 . osputy tjkm.t7 ORIG. DEPT. : Public Works Transportation Planning cc: Public Works - Accounting Auditor-Controller RESOLUTION NO. 83/921 THE BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Adopted this Order on July 26, 1983 by the following vote: AYES: Supervisors Fanden, McPeak, Torlakson, Schroder NOES: . None ABSENT: Supervisor Powers ABSTAIN: None RESOLUTION NO. 83/ 922 SUBJECT: In the Matter of Approving Plans and Specifications for Pinehurst Road Slides Repair, Project No. 0671-6R6311-83, Moraga Area. WHEREAS the Public Works Director has filed this day with the Board of Supervisors, Plans and Specifications for Pinehurst Road Slides Repair; and r WHEREAS the general prevailing rates of wages, which shall be the minimum rates paid on this project, have been filed with the Clerk of this Board and copies will be made available to any interested party upon request; and WHEREAS the estimated contract cost of the project is $56,000; and WHEREAS this project is considered exempt from Environmental Impact Report requirements as an Emergency Project under County Guidelines, the Board hereby concurs in this determination and directs the Planning Director to file.a Notice of Exemption with the County Clerk. IT IS BY THE BOARD RESOLVED that said Plans and Specifications are hereby APPROVED. Bids for this work will be received on August 25, 1983 at 2:00 p.m. , and the Clerk of this Board is directed to publish Notice to Contractors in accordance with Section 1072 of the Streets and Highways Code, inviting bids for said work, said Notice to be published in CONTRA COSTA SUN. 1 hereby certify that this Is a true and correct copy of an action taken and entered on the minutes of the Board of Supervisors on the date shown. ATTESTED: JUL 2 61983 J.R. OLSSON, COUNTY CLERK and ex officio Clerk of the Board ZBy , Do" Orig.Dept.: Public Works Department Design and Construction Division cc: County-Administrator County Auditor-Controller Public Works Director Design and Construction Division Accounting Division DC.PINEHURSTBO.BW RESOLUTION NO. 83/922 1 THE BOARD OF SUPERVISORS CONTRA COSTA COUNTY. CALIFORNIA Adopted this Resolution on July 26, 1983, by the following vote: AYES: Supervisors Randen, McPeak, Torlakson, Schroder NOES: None ABSENT: Supervisor Powers SUBJECT: Intention to Adopt Resolution RESOLUTION NO. 83/ q 2� of Necessity to Acquire (C.C.P. Section 1245.235) Real Property by Eminent Domain Valley View Road Widening Project No. 0662-6R4470 El Sobrante Area RESOLUTION OF INTENTION TO ADOPT RESOLUTION OF NECESSITY The Board of Supervisors of Contra Costa County, RESOLVES THAT: It intends to Adopt a Resolution of Necessity for the acquisition by eminent domain of real property in the El Sobrante area, for the improvement of Valley View Road, a public improvement, which property is more particularly described in Appendix "A" attached hereto. This Board will meet on August 16, 1983 at 10:30 a.m. in the Board' s Chambers, County Administration Building, 651 Pine Street, Martinez, California, to hear those persons whose property is to be acquired and whose names and addresses appear on the last equalized County assessment roll, and to consider the adoption of the Resolution. The Real Property Division is DIRECTED to send the following notice to each such person by first-class mail: NOTICE OF INTENTION TO ADOPT RESOLUTION OF NECESSITY The Board of Supervisors of Contra Costa County declares its intention to adopt a Resolution of Necessity for the acquisition by eminent domain of real property in the El Sobrante area for the improvement of Valley View Road a public improvement, which property is more particularly described in Appendix "A" attached hereto. The Board will meet on August 16, 1983 at 10:30 a.m. in the Board's Chambers at 651 Pine Street, Martinez, California, to consider the adoption of the Resolution. Each person whose property is to be acquired and whose name and address appears on the last equalized County assessment roll has the right to appear at such hearing and be heard on: 1. Whether the public interest and necessity require the project; and 2. Whether the project is planned and located in the manner that will be most compatible with the greatest public good and the least private injury; and 3. Whether the property sought to be acquired is necessary for the project; and 4. Whether the offer of just compensation required by Section 7267.2 of the Government Code has been made to the owner of record. I hereby certify that this is a true and correc Orig. Dept.: Public Works Department-Real Property an action taken and entered on the minut cc: Public Works Accounting Board of Supervlsors on the date shown. County Counsel ATTESTED: JUL 2 61983 Property Owners via R/P (2) J.R. OLSSON, COUNTY CLER and ex officio Clerk of the Boa RESOLUTION NO. 83/ 923 ` B00726.t7 By ` a s R/P -Valley View Road R/W - Higland Estates APPENDIX •A' a Fee Parcel 3B: A portion of Rancho E1 Sobrante, County of Contra Costa, State of California described as follows: Beginning at the most easterly corner of the parcel of land described as "Parcel One" in deed to Contra Costa County, recorded September 10, 1981 , in Book 10483, at page 41, Official Records of said County; thence along the northeast line of said Contra Costa County "Parcel One" (10483 OR 41) , North 520 07' 30" West 45.89 feet to the most northerly corner of said Contra Costa County "Parcel One" (10483 OR 41), being a point on the northwest line of that parcel of land conveyed to Highland Estates, Inc. , recorded May 5, 1980, in Book 9840, at page 805, Official Records of said County; thence along said northwest line (9840 OR 805) , North 390 20' 30" East, 3.64 feet to a point, hereinafter referred to as "Point C;" thence leaving said northwest line, South 530 03' 37" East 45.71 feet to a point, hereinafter referred to as "Point B," on the southeast line of said Highland Estates, Inc, parcel (9840 OR 805) ; thence along said southeast line South 360 37' 30" West 4.39 feet to the point of beginning. Containing an area of 184 square feet or .004 acres of land more or less. Slope Easement Parcel 3C: Beginning at previously described "Point B," thence North 530 03' 37" West 45 .71 feet to previously described "Point C;" thence North 390 20' 30" East 9.36 feet along the northwesterly line of said Highland Estates, Inc. , Parcel (9840 OR 805 ) ; thence south 620 32' 41" East 27.70 feet; thence South 550 17' 45" East 17.94 feet to a point on the southeasterly line of said Highland Estates, Inc. , Parcel ; thence South 360 37 ' 30" West 14.61 feet to "Point B," the point of beginning. Excepting therefrom: All of "Parcel Two" conveyed to Contra Costa County recorded September 10, 1981 , in Book 10483, at page 41 , Official Records of said County. Parcel 2D contains an area of 369 square feet or .008 acres of land more or less. Temporary Construction Easement to expire September 1 , 1984 described as follows: A 10 foot in width stip of land, the southerly line of which is the northerly line of slope easement Parcel 3C hereinbefore described. 00 THE BOARD OF SUPERVISORS CONTRA COSTA COUNTY. CALIFORNIA 'Adopted this Order on July 26, 1983 , by the.following vote: AYES: Supervisors Fanden, McPeak, Torlakson, Schroder NOES: None ABSENT: Supervisor Powers SUBJECT: Right of Way Acquisition Valley View Road Project No. 0662-6R4470 El Sobrante Area IT IS BY THE BOARD ORDERED that the following Right of Way Contracts are APPROVED, and the following Deeds are ACCEPTED: Payee and Grantor Document Date Escrow Number Amount James Hawkins Right of Way 7-12-83 Western Title $49418.00 Contract Insurance Co. Deed 7-12-83 Escrow W-485619 Payment is for 1 ,227 square feet of residential land, a 2,142 square foot slope easement, a 2,052 square foot temporary work area, and miscellaneous vegetation. Grantor Document Date Payee Amount Marilyn Wilson Right of Way 7-13-83 Marilyn Wilson $19051.00 Lane Contract Lane Deed 7-13-83 Payment is for 201 square feet of residential land, a 436 square foot slope easement, a 1,064 square foot temporary work area, and miscellaneous vegetation. The County Public Works Director is AUTHORIZED to execute the above Right of Way Contracts on behalf of the County. The County Auditor-Controller is AUTHORIZED to draw warrants in the amount specified to be forwarded to the County Real Property Division for delivery. The Real Property Division is DIRECTED to have said Deeds recorded in the Office of the County Recorder. (hereby cerflty that dila is a true andcorrecf copy*? an action ?aken and entered on the minutes of the Board of Supervisors on tho data shown. ATTESTED: JUL 2 6 1983 J.R. OLSSOfd, COUNTY CLERK and ex officio Cleric of the Board Orifi Dept,:Pub 1 i c Work s (RP) By , Deputy CC:county Auditor-Controller (via R/P) P.W. Accounting B00726.t7 00 THE BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Adopted this Order on July 26, 1983 by the following vote: AYES: Supervisors Fanden, McPeak, Torlakson, Schroder. NOES: None ABSENT: 'Supervisor Powers. ABSTAIN: None SUBJECT: of the Final Map for ) RESOLUTION NO. 83/924 Subdivision 6324 (Reversion to Acreage of ) Lots #15 through #31 of Subdivision 5967 3 and Abandonment of Sunset Boulevard), San Ramon Area. ) . The following document was presented for Board approval this date: The Final Map of Subdivision 6324, property located in the San Ramon area, said map having been certified by the proper officials; Said Final Map of Subdivision 6324 is a reversion to acreage of Lots #15 through #31 of Subdivision 5967, recorded June 23, 1981 in Book 253 of Maps at page 49. On May 18, 1983, the San Ramon Valley Planning Commission has resolved, by Resolution 16-1983(SR) , that the reversion to acreage is appropriate and has recommended to this Board that Sunset Boulevard be abandoned, based on the following findings: 1. Dedications (including Sunset Boulevard) and offers of dedication proposed to be vacated or abandoned by the reversion to acreage and associated abandonment are unnecessary for present or prospective public purposes as evidenced by the transmittal from the Public Works Department of the County of Contra Costa dated January 7, 1983, wherein the department advised of their concurrence with the applicant's request for reversion and abandonment based on the fact that Sunset Boulevard is not in conformance with the submitted development proposal and is unnecessary for present or prospective public purposes. 2. The Pacific Telephone and Telegraph Company, as sole owners of the real property identified as Lots #15 through #31 of Subdivision 5967 have consented to the reversion and abandonment. This Board hereby FINDS that the dedication of Sunset Boulevard for public use (shown on the Final Map of Subdivision 5967 (253 M 49) and accepted by this Board on July .6, 1982 (10840 OR 584) ) , is unnecessary for present or prospective use, and it is HEREBY ORDERED VACATED (abandoned) . NOW THEREFORE BE IT RESOLVED that said subdivision is DETERMINED to be consistent with the County's General and Specific Plans. y BE IT FURTHER RESOLVED that said Final Map is APPROVED and this Board does not accept or reject on behalf of the public any of the streets, paths, ' or easements shown thereon as dedicated to public use. I hereby certify that this is a true and correct copy of an action taken and entered on the minutes of the Board of Supervisors on the date shown. ATTESTED: J U L 2 61983 J.R. Oi.SSON, COUNTY CLERK and ex officio Clerk of the Board @IDeputy Originator: Public Works (LD) cc: Director of Planning Public Works - Des./Const. Trans. Planning Maintenance Assessor County Counsel Recorder, via Land Dev. , then PW Records Pacific Telephone & Telegraph Co. Attn: Warren C. Sweet W. Crocker Tower 1 Montgomery St., Room 412 San Francisco, 94104 EBMUD, Land Dept. P. 0. Box 24055 Oakland, CA 4623 Thomas Bros. Maps 550 Jackson Street San Francisco, CA 94133 Pacific Telephone, R/W Supv. 1879 Olympic Blvd., Room 203A Walnut Creek, CA 94596 PG&E 1030 Detroit Avenue Concord, CA 94518 San Ramon Valley Fire Protection Dist. 800 San Ramon Valley Blvd. Danville, CA 94526 RESOLUTION NO. 83/924 RECORD: Sub 5967, Sub 6324, SUNSET BOULEVARD 80726.t7 0 0 THE BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Adopted this Order on July 26, 1983 by the following vote: AYES: Supervisors Fanden, McPeak, Torlakson, Schroder. NOES: None ABSENT: Supervisor Powers. ABSTAIN: None SUBJECT: Approving Deferred Improvement Agreement along Pacheco Boulevard, Pacheco Area. Assessor's Parcel No. 161-231-001 and 002. The Public Works Director has recommended that he be authorized to execute a Deferred Improvement Agreement with Charles S. O'Conner, et al, . This agreement would permit the deferment of construction of permanent improvements along the south side of Pacheco Boulevard, opposite Camino Del Sol , which is located in the Pacheco area. These improvements are required to be assured pursuant to Title 10 of the Ordinance Code prior to the issuance of a building permit. IT IS BY THE BOARD ORDERED that the recommendation of the Public Works Director is APPROVED. I hereby certify that this is a true and correct copy of an action taken and entered on the minutes of the Board of Supervisors on the date shown. ATTas T IED: JUL 2 61983 J.R. Ot$S©N, COUNTV CLERK and ex officlo Clerk of the Board By �� , Deputy Orig. Dept. : Public Works (LD) cc: Recorder, (via LD) then PW Records, then Clerk of the Board Director of Planning Charles S. O'Conner, et al c/o Diablo Petroleum 4333 Pacheco Boulevard Martinez, CA 94553 B0726.t7 4 THE BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Adopted this Order on July 26 1983 by the following vote: AYES: Supervisors Fanden, MCPeak, Torlakson, Schroder. NOES: None ABSENT: Supervisor Powers. ABSTAIN: None SUBJECT: Authorizing Acceptance of Instrument. IT IS BY THE BOARD ORDERED that the following instrument is hereby ACCEPTED FOR RECORDING ONLY-- INSTRUMENT NLY:INSTRUMENT REFERENCE GRANTOR AREA Offer of Dedication Building Permit Charles S. Pacheco for Roadway Purposes O'Conner, et al . I herdby cerPty that this Is a true and correct copy of on noon oaken and entered on the minutes of the aoe of CupeMsors on the date shown. ,r'n+: JUL 2 61983 J.l*. 0t.SSOM, COUNTY CLERK and ex officio Cierk of the Board By , Deputy Orig. Dept. : Public Works (LD) cc: Recorder (via LD) then PW Records Director of Planning THE BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Adopted this Order on July 26, 1983 by the following vote: AYES: Supervisors Fanden, McPeak, Torlakson, Schroder NOES: None ABSENT: Supervisor Powers ABSTAIN: None SUBJECT: Completion of Improvements, ) Subdivision 5523, ) RESOLUTION NO. 83/925 Byron Area. ) The Public Works Director having notified this Board that the improve- ments in Subdivision 5523 have been completed as provided in the Subdivision Agreement with S.S.B.I. Associates heretofore approved by this Board in conjunction with the filing of the Subdivision Map; and NOW THEREFORE BE IT RESOLVED that the improvements have been COMPLETED for the purpose of establishing a six-month terminal period for the filing of liens in case of action under said Subdivision Agreement: DATE OF AGREEMENT SURETY October 20, 1981 Developers Insurance Company Bond No. 103507 BE IT FURTHER RESOLVED that the Public Works Director is AL MdFtIZED to refund the $1,000 cash security for performance (Auditor's Deposit Permit No. 45286, dated October 8, 1981) to Wilhelm Construction Company pursuant to the requirements of the Ordinance Code. I hereby certify that this Is a true and correct copy of an action taken and entered on the minutes of the Board of Supervisors on the date shown. AT1iZ TED: JUL 2 S 1983 J.R. CLSSOH, COUNTV CLERK and ex officio Clerk of the Board By rn , Deputy Originator: Public Works (LD) cc: Public Works - Accounting - Des./Const. S.S.B.I. Associates 2255 Ygnacio Valley Road, Suite A Walnut Creek, CA 94598 Developers Insurance Co. 5152 Katella Avenue, Suite 102 Los Alamitos, CA 90720 Wilhelm Construction Co. P. 0. Box 4717 Walnut Creek, CA 94596 60726.t7 RESOLUTION NO. 83/925 O 1 2 THE BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Adopted this Order on July 26, 1983 , by the following vote: AYES: Supervisors Fanden, McPeak, Torlakson, Schroder NOES: None ABSENT: Supervisor Powers ABSTAIN: None SUBJECT: In the Matter of Accepting ) RESOLUTION OF ACCEPTANCE and Giving Notice of ) AND NOTICE OF COMPLETION Completion of Contract with ) (C.C. SECS. 3086, :3093) P&F Construction , Inc. , ) RESOLUTION NO. -8 3/926 Assessment District 1982-19 ) San Ramon Area. ) The Board of Supervisors of Contra Costa County RESOLVES THAT: The County of Contra Costa, 651 Pine Street, Martinez, California, on May 25, 1982, contracted with P&F Construction, Inc. for the widening and improvement of Bollinger Canyon Road from Crow Canyon Road to a point approximately 940 feet northerly thereof, and the extension of Deerwood Drive from Bollinger Canyon Road to Subdivision 5475; and The Public Works Director reports that said work has been inspected and complies with the approved plans and specifications and recommends its acceptance as complete as of July 26, 1983. Therefore, said work is ACCEPTED as completed on said date, and the Clerk shall file with the County Recorder a copy of this Resolution and Notice as a Notice of Completion for said contract. 1 heroby eertity that this Is a tmm endconect copy of an action taken and entered on the mir,vtos of the Board of SuperrIzcA*. on the tato ohown. ATTESTED:_ JA_� A(0, i 9 93 J.R. OLS3ON, COUNTY CLERIC and ex o:ficlo Clark of the Board By ,Deputy Originator: Public Works (LD) cc: Public Works - Des/Const. - Accounting County Administrator Auditor-Controller Recorder P&F Construction, Inc. 3737 Broadway 013 Oakland, CA 94611 RESOLUTION CVO. 83/926 BOX726.t8 THE BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Adopted this Order on July 26, 1983 by the following vote: AYES: Supervisors Fanden, McPeak, Torlakson, Schroder NOES: None ABSENT: Supervisor Powers ABSTAIN: None SUBJECT: Completion of Warranty Period and Release of Cash Deposit for Faithful Performance, Subdivision 5252, E1 Sobrante Area. On April 21, 1981, this Board resolved that the improvements in Subdivision 5252 were completed as provided in the Subdivision Agreement with Carter Construction Company and now on the recommendation of the Public Works Director; The Board hereby FINDS that the improvements have satisfactorily met the guaranteed performance standards for one year after completion and accept- ance; and IT IS BY THE BOARD ORDERED that the Public Works Director is AUTHORIZED to refund the $1,000 cash deposit (Auditor' s Deposit Permit No. 17050, dated February 15, 1979) to Carter Construction Company, pursuant to Ordinance Code Section 94-4.406 and the Subdivision Agreement. 1 hereby certify that this is a arae ardconecfewof an action taken and entered on the minutos of the Board of Superviso jUqn t�o,Mown. ATTESTED: � b J.R. 0t_3:!0Ff1, C0_QNTY CLERK and ex officio Clerk of the Board d3r " =—• Dar Public Works (LD) Public Works - Account. - Des./Const. Director of Planning Carter Construction Co. 5121 La Honda Road El Sobrante, CA 94803 American Motorists Ins. Co. Bond No. 9SM551425 P. 0. Box 7993 San Francisco, CA 94104 014 130726.0 THE BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Adopted this Order on July 26, 1983 by the following vote: AYES: Supervisors Fanden, McPeak, Torlakson, Schroder NOES: None ABSENT: Supervisor Powers ABSTAIN: None SUBJECT: Completion of Warranty Period and Release of Cash Deposit for Faithful Performance, Subdivision 5393, E1 Sobrante Area. On August 4, 1981 , this Board resolved that the improvements in Subdivision 5393 were completed as provided in the Subdivision Agreement with Alfred M. Dias and now on 'the recommendation of the Public Works Director; The Board hereby FINDS that the improvements have satisfactorily met the guaranteed performance standards for one year after completion and accept- ance; and IT IS BY THE BOARD ORDERED that the Public Works Director is AUTHORIZED to refund the $1,000 cash ,deposit (Auditor ' s Deposit Permit No. 24090, dated Ocober 15, 1979) to Alfred M. Dias, pursuant to Ordinance Code Section 94-4.406 and the Subdivision Agreement. I hereby certify that this Is o true and correct copy of an action taken and entered or the minutes of the Board of 3uperylacre.on the date shown. A':'TE,STED: JUL 2 01983 J.R. OLSS©q, CCUNTY CLERK and ex ofiici4 Clerk of the Board By , Deputy Public Works (LD) Public Works - Account. - Des./Const. Director of Planning Alfred M. Dias 230 Amend Court E1 Sobrante, CA 94803 American Motorists Ins. Co. Bond No. 9SM553382 717 Hearst Boulevard Third & Market Streets San Francisco, CA 94103 0 15 60726.0 THE BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Adopted this Order on July 26, 1983 by the following vote: AYES: Supervisors Fanden, McPeak, Torlakson, Schroder NOES: None ABSENT: Supervisor Powers ABSTAIN: None SUBJECT: Completion of Warranty Period and Release of Cash Deposit for Faithful Performance, Subdivision 5046, Alamo Area. On August 10, 1982, this Board resolved that the improvements in Subdivision 5046 were completed as provided in the Subdivision Agreement with Valley Oaks Associates and now on the recommendation of the Public Works Director; The Board hereby FINDS that the improvements have satisfactorily met the guaranteed performance standards for one year after completion and accept- ance; and IT IS BY THE BOARD ORDERED that the Public Works Director is AUTHORIZED to refund the $1,417 cash deposit (Auditor' s Deposit Permit No. 13431, dated October 11 , 1978) to Valley Oaks Associates, pursuant to Ordinance Code Section 94-4.406 and the Subdivision Agreement. 1 hereby certify that this Ic a true and correct copy of an ncUo °cker,and sntomd on the rrinutec of the Dowd of Supc;l;!sers n Che dans tou wn. A YESTED: -JUL 2 6 1983 snad ex officio C;tc=;k ca i!•c EoGrd ey_� 22Ld4&= Deputy Orig. Dept. : Public Works (LD) cc: Public Works - Account. - Des./Const. Director of Planning Valley Oaks Associates 375 Diablo Road, Suite 200 Danville, CA 94526 United Pacific of Washington Bond No. U071328 1355 Willow Way, No. 101 Concord, CA 94520 0 16 B0726.0 THE BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Adopted this Order on July 26, 1983 by the following vote: AYES: Supervisors Fanden, McPeak, Torlakson, Schroder NOES: None ABSENT: Supervisor Powers ABSTAIN: None SUBJECT: Completion of Warranty Period and Release of Cash Deposit for Faithful Performance, Subdivision MS 9-80, Concord Area. On August 10, 1982 this Board resolved that the improvements in Subdivision MS 9-80 were completed as provided in the Subdivision Agreement with Fred Lowe and now on the recommendation of the Public Works Director; The Board hereby FINDS that the improvements have satisfactorily met the guaranteed performance standards for one year after completion and accept- ance; and IT IS BY THE BOARD ORDERED that the Public Works Director is AUTHORIZED to refund the $1,000 cash . deposit (Auditor's Deposit Permit No. 45123, dated October 5, 1981) to Fred Lowe, pursuant to Ordinance Code Section 94-4.406 and the Subdivision Agreement. I hereby certify that this Is a true and correct copy of an actlor taken and entered on tho minutes of the Board of Supervisors on the date shown. ATTESTED: JUL 2 5 1983 J.R. OLSSCIN, C.-)UNTY CLERK and ex or'rtefo Clark of the Board B , Deptq Orig. Dept. : Public Works (LD) cc: Public Works - Account. - Des./Const. Director of Planning Fred Lowe P. 0. Box 5757 Concord, CA 94524 St. Paul Fire & Marine Ins. Co. Bond No. 400 GG 2257 100 California St. San Francisco, CA 94111 017 B0726.t7 THE BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Adopted this Order on 1111V 26- AQW, by the following vote: AYES: Supervisors Fanden, McPeak, Torlakson, Schroder NOES: . None ABSENT: Supervisor Powers ABSTAIN: None SUBJECT: Approval of Reimbursement Agreement with the Hofmann Company, Drainage Area 29C, Oakley Area - Project No. 7555-6D8573 IT IS BY THE BOARD ORDERED, as the Governing Body of the Contra Costa County Flood Control and Water Conservation District, that the Reimbursement Agreement with the Hofmann Company for the installation of drainage improvements in conjunction with the development of Subdivision 6010 is APPROVED, and the Chairperson is AUTHORIZED to execute the agreement on behalf of the District. The payment limit for the Agreement is $27,349.05 which amount provides for reimbursing the Hofmann Company in accordance with the Drainage Fee Credit and Reimbursement Policy for Drainage Area 29C adopted by the Board on March 13, 1979. Further; the agreement provides that no reimbursements are .to be made until the pre-existing County loans are repaid. I hereby certify that this Is a true and correct copy of an action taken and enterad on the minates of the Board of Superviyon;on the date shown. JUL 2 6 1983 J.R. 01.2140N, Ci''i_IN9T Y CLERK and ex offlcl^ Clerk of the Board Bp Deputy Orig.Dept.: Public Works - FC cc: County Administrator Public Works Director Accounting Flood Control Auditor-Controller Hofmann Company, PO Box 907, Concord, CA 94522 bo:HofmannDA29C.t7 018 rW 7 THE BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Adopted this Order on July 26, 1983 by the following vote: AYES: Supervisors Fanden, McPeak, Torlakson, Schroder NOES: None ABSENT: Supervisor Powers ABSTAIN: None SUBJECT: Adopting a Drainage Fee Credit and Reimbursement Policy and Approving a Drainage Area Agreement for Flood Control Drainage Area 56, Antioch Area . The Public Works Director has recommended that the Board of Supervisors adopt the attached Drainage Fee Credit and Reimbursement Policy and approve a Drainage Area Agreement for Drainage Area 56. The Drainage Fee Credit and Reimburse- ment Policy ensures equal treatment of property owners in the area and establishes reimbursement criteria and procedures. The Agreement provides for City of Antioch, County and District cooperation in administering, collecting, and accounting of drainage fees required by the Drainage Fee Ordinance for Drainage Area 56, acquisition of project rights-of-way, and for maintenance of the completed drainage facilities. IT IS BY THE BOARD ORDERED, as the Board of Supervisors of Contra Costa County and as the governing body of the Contra Costa County Flood Control and Water Conservation District, that said Drainage Fee Credit and Reimbursement Policy is ADOPTED, and said Drainage Area Agreement is APPROVED, and the Chairman is AUTHORIZED to execute the agreement on behalf of the District and the County for Drainage Area 56. 1 hereby certify that thle is a true and correct copy of an adlon taken and entered on the minutes of the Board of Supen•isore en the date shown. A�.E3pED: JUL 2 6 1983 J.R. OLSMN,,, C107J i?Y CLERK and ox of hAv Cie:-k or tho Board Orig.Dept.: Public Works-FCP 21� , cc: County Administrator BZu Deputy County Auditor-Controller Public Works Department Flood Control Planning Accounting City of Antioch Attachment-2 bo:mfkDA56feecrd.t7 019 EXHIBIT I DRAINAGE FEE CREDIT AND REIMBURSEMENT POLICY DRAINAGE AREA 56 (ANTIOCH) The following policy adopted on JUL 2 6 1983 by the Board of Supervisors, as the governing body of the Contra Costa County Flood Control and Water Conservation District, shall be used in the administration of the Contra Costa County Flood Control and Water Conservation District Drainage Fee Ordinance No. 82-10 for Drainage Area 56. I. GENERAL A. Developers installing drainage facilities shown on the adopted drainage plan may be eligible for credit against the required drainage ,fees and for reimbursement of costs in excess of the drainage fees. The amount of credit or reimbursement shall be limited to the summation of the following eligible costs: 1. Actual in-tract and off-tract construction costs plus a fixed amount of 7% of the in-tract construction cost and 14% of the off-tract construction cost for allowance of miscellaneous developer's costs, including contract preparation, engineering, bonding, etc. 2. Actual public agency project inspection fees. 3. Actual off-tract utility relocation costs. 4. Purchase price for the off-tract right of way acquired by the District and paid for by the developer, provided the developer does not have a beneficial interest in the off-tract property. B. The determination of construction costs that will be eligible for credit or reimbursement will be based on at least three independent bids for the drainage facilities work. The developer shall submit said bids to the District for review and concurrence. Upon District concurrence with the bids, the lowest bid shall be the basis for determination of the credit and reimbursement amount. The District reserves the right to reject the developer ' s bids or any other proposed value of said eligible costs and to calculate said costs using then current prices. C. If the developer elects to install a more costly drainage system than shown on the adopted plan, the District reserves the right to calculate said eligible costs using the then current prices for only the facility shown on the adopted plan. II. CREDIT POLICY The. developer is eligible to receive credit for the construction of drainage facilities up to an amount equal to the required drainage fee computed in conformance with Drainage Fee Ordinance 82-10 for Drainage Area 56 and Section I above. III. REIMBURSEMENT POLICY A. Where the amount of said eligible costs exceed the drainage fee due, the developer, upon entering into a reimbursement agreement with the District, shall be eligible for a percentage reimbursement on the amount of the eligible costs determined by Section I above, in excess of the drainage fee due as follows: Group A: 100 % (One Hundred Percent) for off-tract work. Group B: 50% (Fifty Percent) for in-tract work. 1 020 ' Prior to the application of the above percentages, the eligible costs in excess of the drainage fee due shall be prorated between Group A and B in the same proportion as the total eligible costs for Group A and B are to the total eligible costs. B. The reimbursement shall be subject to the following limitations: 1. Reimbursements shall be paid only from drainage fees collected under Ordinance No. 82-10. 2. If more than one reimbursement agreement is in effect, the reimbursement payments to each developer shall be based on the ratio of the developer' s outstanding balance to the total outstanding balance of all agreements. 3. The District reserves the right to utilize only eighty (80) percent of the fees collected annually, on a fiscal year basis, for the purpose of making reimbursement payments. 4. Reimbursement payments shall be made quarterly, except that, during any quarter the District reserves the right not to make said payments if the amount of available funds to be disbursed is less than $5,000, and the total outstanding balance (reimburse- ments owed to all parties) is greater than $5,000. 5. Reimbursement agreements shall remain in effect for 40 annual quarters . The first quarter shall be the one following the quarter in which the County accepts the drainage facilities installed as complete. Any outstanding balance owed at the end of the 40 quarters shall be waived by the developer. IV. EXAMPLE Attached hereto as Exhibit A. and made a part hereof, is an example illustrating the implementation of the Credit Policy (Section II ) and the Reimbursement Policy (Section III) . 2 021. DRAINAGE FEE CREDIT AND REIMBURSEMENT IMPLEMENTATION DRAINAGE AREA 56 EXAMPLE 1 A. ASSUMPTION 1. Development is creating 70 residential sites having lot areas between 7,000-7,999 square feet and 60 patio homes sites having lot areas between 3,000-3,999 square feet. 2. The eligible off-tract costs (Group A) are $100,000. (Policy Section I.A.) 3. The eligible in-tract costs (Group B) are $50,000. (Policy Section I.A.) B. FACT 1. Fee for 7,000-7,999 square foot lots is $1,360. (Ordinance Section VII) 2. Fee for 3,000-3,999 square foot lots is $620. (Ordinance Section VII) 3. Reimbursement of off-tract (Group A) excess cost is 100%. (Policy Section III.A. ) 4. Reimbursement of in-tract (Group B) excess cost is 50%. (Policy Section III.A.) C. FEE CALCULATION Fee Due = (70 lots x $1,360/lot) + (60 lots x $620/lot) Fee Due = $95,200 + $37,200. Fee Due = $132,400. D. CALCULATION OF REIMBURSEMENT Eligible Costs Group A $100,000. Eligible Costs Group B 50000. Total Eligible Costs TF509000. Less Fee Due 132 400. 7,600. Ratio of Group A. Group B to total Eligible Costs (Policy Section III.A.) : Group A = $100,000 2 Group B = $50 000 = 1 $150,000 3 150,000 3 Therefore, the excess is prorated3 to Group A and to Group B. Group A Reimbursement = (100%) ($17,600) (3) _ $11,733.33 Group B Reimbursement = (50%) ($17,600) (3) = 2,933.33 Total Amount of Reimbursement would be $14,666.66 FC.DRAINFEECREDREIMB56.PC 3 EXHIBIT A 022 THE BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Adopted this Order on July 26 , 1983 , by the following vote: AYES: Supervisors Fanden , McPeak, Torlakson, Schroder. NOES: None. ABSENT: Supervisor Powers . ABSTAIN: None. SUBJECT: SALE OF TAX DEEDED PROPERTY TO THE CITY OF WALNUT CREEK •IT IS BY THE BOARD ORDERED that the Chairman is AUTHORIZED to execute an Agreement of Sale entered into between the County of Contra Costa, City of Walnut Creek and the State of California, for the sale of Parcel No. 169-331-007 to the City of Walnut Creek, pursuant to Revenue and Taxation Code Sections 3791 et seq., as recommended by the County Treasurer-Tax Collector. 1 hereby certify that this is a true and correct copy of an action taken and entered on the minutes of the Board of Supervisors on ti o dote shown. ATTESTED: J.R. OL SON, COUNTY CLERk and ex officio Clerk of the Board . Deputy Orig. Dept.: Treasurer-Tax Collector cc: State of California c/o Tax Collector .(6) Auditor-Controller Administrator City of Walnut Creek 023 S �- In the Board of Supervisors of Contra Costa County, State of California July 26 . , 19 &1 1n the Matter of Approval of Refund(s ) of Penalty(ies) on Delinquent Property Taxes . As recommended by the County Treasurer-Tax Collector IT IS BY THE BOARD ORDERED that refund(s) of penalty(ies) on delinquent property taxes is (are) APPROVED and the County Auditor-Controller is AUTHORIZED to refund same as indicated below: APPLICANT PARCEL NUMBER AMOUNT OF REFUND Jerry Regan 197-310-053-8 10% Pen $81.15 140 Alamo Square Cost 5.00 Alamo, CA 911507 Crocker Homes, Inc. 076-031-025-0 10,2 Pen $10,686.50 One Post Street Cost 5.00 San Francisco, CA 9111011 PASSED by the Board on July 26, 1983 1 hereby certify that the foregoing Is a true and correct copy of on order entered on the minutes of said Board of Supervisors on the date aforesaid. cc: County Auditor-Controller Witness my hand and the Seal of the Board of County Treasurer-Tax Supervisors Collector affixed this 26th day of- July 19-83 Applicant J. R. OLSSON, Clerk By Deputy Clerk 024 H-24 4/77 15m ��/k t In the Board of Supervisors of Contra Costa County, State of California July 26 . .6 19 S3_, r In the Matter of DENIAL OF REFUND(S) OF PENALTY(IES) ON DELINQUENT PROPERTY TAXES AS RECOMMENDED BY THE COUNTY TREASURER-TAX COLLECTOR IT IS BY THE BOARD ORDERED THAT THE FOLLOWING REFUND(S) OF PENALTY(IES)ON DELINQUENT PROPERTY TAXES IS (ARE) DENIED: APPLICANT PARCEL NUMBER AMOUNT William Harold Bird, Jr. 184-410-051-9 10% Pen $116.90 1640 Fieldgate Lane Cost 5.00 Walnut Creek, CA 94595 Lewis Epstein 085-092-002-6 10% Pen $8.65 614 Vermont St. Cost 5.00 San Francisco, CA 94107 Ugo Jacuzzi` 245-031-009-5 lOS Pen $84.46 3737 Meadow Lane Cost 5.00 Lafayette, CA 94549 Janice Gail Walley' 268-462-020 10% Pen $111.17 14 Evergreen Drive Cost 5.00 Orinda, CA 94563 PASSED BY THE BOARD ON July 26, 1,983 1 hereby certify that the foregoing b a true and correct copy of an order entered on the minutes of said Board of Supervisors on the date aforesaid. CC : !/COUNTY TREASURER-TAX Witness my hand and the Seal of the Board of COLLECTOR Supervisors affixed thls2 6�Z day of T,a i y 19-. APPLICANT J. R. OLSSON, Clerk gy Deputy Clerk 025 H-24 3179 15M ► �,F//i�� a In the Board of Supervisors of Contra Costa County, State of California July 26 , 19 83 In the Matter of Approval of Refunds ) -of Penalty(ies) on Delinquent Property Taxes . As recommended by the County Treasurer-Tax Collector IT IS BY THE BOARD ORDERED that refund(s) of penalty(ies) on delinquent property taxes is (are) APPROVED and the County Auditor-Controller is AUTHORIZED to refund same as indicated below: APPLICANT PARCEL NUMBER AMOUAT OF REFUND James Frederick Hargis 144-140-087-4 10% Pen $174.56 P. 0. Box 299 Cost 5.00 Prineville, Oregon 97754 Cruz S. & 0-t R4ck Hernandez 089-306-011-1 10% Pen $50.50 71 Laguna Circle Pittsburg, CA 94565 Town & Country Food Services and a. 517-100-027-5 a. 10,8 Pen $421.83 Cal camp Co., Inc. b. 170-280-036-6 b. 10% Pen $585.94 2955 N. Main Street Walnut Creek, CA Raymond Casso 134-282-003 10,E Pen $32.91 780 Tiffany Place Cost 5.00 Concord, CA 94518 PASSED by the Board on July 26 , 1983 1 hereby certify that the foregoing is a true and correct copy of an order entered on the minutes of said Board of Supervisors on the date aforesaid. cc: County Auditor-Controller Witness my hand and the Seal of the Board of County Treasurer-Tax Supervisors Collector affixed this 26th day of July . 19_,3 Applicant J. R. OLSSON, Clerk By61"�L Deputy Clerk 026 H-24 4/77 15m 1. 71K BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Re: Assessment Roll Changes AOU 83.3 The Contra Costa County Board of Supervisors RESOLVES THAT: As requested by the County Assessor and, when necessary, consented to by the County Counsel (see signature(s) below), and pursuant to the provisions of the California Revenue and Taxation Code incorporated herein, (as explained by the tables of sections, symbols and abbreviations attached hereto or printed on the back hereof), and including data recorded on Auditor approved forms attached hereto and marked with this resolution number, the County Auditor is hereby ordered to make the addition, correction and/or cancellation to the assessment roll(s) as indicated. Requested by Assessor By 5 +� PASSED ON JUL 2 6 IM Joe a, Assistant Assessor unanimously by the Supervisors present. When requir by law, consented to by the o ty Counse ByPage 1 of 40 Chief, Va 'on / !hereby cortily that th/s is a true and correctcop y& Copies: Auditor an anion taka.� and ent;�rmd an the Assessor Board 0t SUDarvlsors on the date shown.ies of the Tax Collector #1; M105-M107; E45-E80 ATTESTED: JUL 2 61983 J.R. OLSSON, COUNTY CLERK and en officio Clerk of the Board By • , Deputy A 4042 12/80 AOU 83.8 L 027 1 CONTRA COSTA COUNTY C0103ERCIAL FISH BOAT AUDITORS OFFICE BUSINESS PERSONALTY SYSTEM—UNSECURED / AUDITOR MANUAL BILL ' NAME o,oZ l Aklal s��Sx/c CORR. N0. JACCOUNT N0. A5— 3 TRA: ? 5 IROLL YEAR 19--.2- FULL VALUE PENALTY F.Y. EXEMPTIONS A.V. VALUE TY,PE CD AMOUNT CD _AMOUNT_ CD TYPE NO. AMOUNT LAND Al A2 Al IMPROVEMENTS Al A2 AI PERSONAL PROP AI_ _ A2 _ _ Al PROP STMNT IMP Al — A2 Al TOTAL S UNSECURED PROPERTY TAX DATA CD FUND REVENUE LC DESCRIPTION AMOUNT 4qp 00 NOT PUNCH 8 61 1003 9020 COUNTY TAX _ BI BI BI F LL I L S DO NOT PUNCH .4w ELMNT ELEMENT DATA DESCRIPTION NO. 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W N — O e+ 0 . m m y: T W lD m T t0 I I w t0 m rn _ — — — O :1D mT - T2J r" 0 0 o c oo o o z z 0 m v r — m z o m �� y r v z o m v v r - o W w w v (n m y - m y ID 3 m m y - m to �D 3 m m y - m N D m �' CO m z _ Iz z y x in Iz z y x z z s x D v o m a v m m CD 3 rt < z 3 < z x r 3 < v tp to to eo < 1n J m v K m ) m o m lj o x . y s o l0 0 0 m rn X 1 rn x r z 3 0 Pb O 10 O O C m ro I vl 'U m 2 ym -� � N CA x D A l7 O a H a v n in c W HAIA m Z rt m C' to m ...I 0 m z o o _ m y X Z r 0 I m -, o I ; H y c En �aJ n z C i In o A T = S A m 065 „awnr�* xo >rrt o :�t off3JVd oa - g” � 0 m n V r D D 0 p tw 74pol Fj w w A a n a m m mm moN nl N = X X X X D = 10 ; O v 0 w D Z 1-. m r m m ;. m m C v v v 0 n : r f r r A D z Ts o to z 1� C y a N O 01010 O IO IO 10 s a m r A (rn ^ m 0 -t h� >i; a IN m r w Iw Iw w IIw :w (w Iw o ; ^� ,- c f z � " r- z r ; z OD t0 �N I� 1°i.�u IA fA I^' < iD z m r^ v �� ~ Iz O fl1 4 �o IM n m m o x w -4 s x Imin -1. ; h .0 rA V �� to m z m s IV m e c rrt T D I= M I � A m O T r ._ T T w w Ito iw w .I 'q ti -4 w w w O o = ID s ala 0o r < 1 N N N N �N -J O� C-4 A U A W G� z o m w �c r v M -1 �- m IN D 3 m t7 N N 'N N 1 D 'o m V 4t i U C '.I S m z Z .ti T m x *0 �' v m O I 3 3 1 (m m '� m T n n — c i T 0 Z 1 y m z m � -1 a� rn v m z < N 1 ccr D m C N Z Z O n yO t7 O \ A m T N N N N O m Z �^ z ; I I z m T x 1 I N O A D < m m o 3 c a. 0 M m m Z :U O z D r z ~ O -4 -< m 0 - c�p ^ m m r O z V m m z -+ n 3 Oq T O N C . La u+ W w w Iw w w w w w u+ W w lo w w w w w w w w w �- z N iN N N iN IN N N N IN N �N N N N N IN N N N N N N N Z D D b m n th tn oto 00 0 IO 0 0 0 0 IO IO 0 0 IO IO 0 0 0 0 0 0 O z 41 z N 41 T (n U U U U U U IU ,U U U A A -i m A A A A A A y W IN — O t0 l4) V 0 U IA �W iN O •t4 Im V 47 U A w N — O m m m m m m m 0 m N T o m D o c 00 0 o z L-4 w w v D z o m v �m r v z o m v v D r - v z o m v r v m -1 - m N la ; m m 1 - m N I3 m m 1 - m a cn -1 2 m Z Iz m -i S m z z Im --1 S z y Z v m A X D ; 0 0 X D O O -0 m D O ^� m C/1 4 ' I < m -0 < z X r ; < v -"i to t0 to t0 < (n X M A m 0 x v l � 0 X ; A � .K O to D o m 3 I I O A sh. 1A. N N Z 3 m 3 O Ln o o O m m z _0 < z Nto T r rN X 0 D C7 a n H O y a b m m C b cTN+ by 0 CA 10 m z v m o m m v z •O T X z 0 En ofrn Z h z 0 o 0 m = 2 A m 066 r BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Re: Assessment Roll Changes /9:03 F3, /0 The Contra Costa County Board of Supervisors RESOLVES THAT: As requested by the County Assessor and, when necessary, consented to by the County Counsel (see signature(s) below), and pursuant to the provisions of the California Revenue and Taxation Code incorporated herein, (as explained by the tables of sections, symbols and abbreviations attached hereto or printed on the .back hereof), and including data recorded on Auditor approved forms attached hereto and marked with this resolution number, the County Auditor is hereby ordered to make the addition, correction and/or cancellation to the assessment roll(s) as indicated. Requested by Assessor By PASSED ON UUL 2 61983 Jo uta', Assistant Assessor unanimously by the Supervisors present. When reV ed by law, consented to by County Co I BY `f � '"''� Page 1 of g Deputy Copies: Auditor Assessor thereby certify that this/s a trusandcorrecteopyof Tax Collector M action taken and entered on the minutes of the Board of Supervisors on the data shown. AT ATTEsrE. ,/i J.R. OLSSO/V, Coutiry CLERK and ex officio Clerk of the Board By . Deputy A 4042 12/80 / 0 067 2 2 ¢ ¢ W O ¢< 0 O U � Lf) C 00 <r C W O) mw U Cr Lf) LP') ¢ 00 00 Cw S w cn Cn O mo a F- • n :)z NU N 00 M r w W < Cr r I QJ < z Z z z z Z z z JZ w O O O O O O O O cm Z w w w w w w w w ¢o= ¢ MWrncn <()Wa H F Q wt: m m �e m m ro m .o O NW U ¢ ¢ ¢ ¢ ¢ ¢ ¢ ¢ J Z <> 2)¢ z M OU p j> 00 00 00 00 00 00 y U O < ¢ ¢ ¢ J¢ J¢% JJ¢ ¢WCz zS om wO ww O UC ZJ I G O O O JJ¢ ¢O UW FYU w>JJ¢ z < QNJw (L J N W ¢ w W r r 00 wz ¢r W > W ?> ¢N < = O ¢� OQ X Jr m < UU ar W < El >dw ¢ ¢ ¢ ¢ ¢ ¢ ¢ ¢ W r r r r r r r r Occ < W Q N > a < < a cc a Q LL 0 CL Wa Z < < U Q Z z > a Cl U Q w a Z fn a a r- 10 O 0: U O A D D r U C 0 J W > Q) U N LL d u: O cn Q ao_ rfo D v w r a �� Q Q JaDo rt3 D pF 3 Z w w N 41 ^ >> N W z L U C U 4J C C W x d F > O 41 Q < N 0 o D 0 z O z Q < L C < J = r F < ^ W ^ ^ > < a z C O • L Z > N • In U < z W N N y N h In In J W W w w W W J ��//�� w O F w w W W W W W W W W W W W W W W LL VJ <zw ^ Wa WQ WQ ^ W< NQ NQ tn< tn< cr r0 w NZ NZ n NZ U)Z w yZ yZ yZ NZEn r < < < Q N !n In W U) Q Q Q A W In WJW2W2F Q In=)LLLL—X , D Ni Q I 1 1 1 1 1 c m 1 C 2 1 1 1 1 1 1 < Z D DO LLI V UQ LL 1 Q I Q.1 Q 1 Q I Q I Q Q Q O O O O O O O a m U) U) n m rn rn 9) m ¢ ¢ ¢ ¢ ¢ O r rn IM w O) O) O m N N m cn 0 O ' w W v 0¢ O u) U) V) N N to U m Q m a� < Q Q OpQ Q Q Q Q a RESOLUTION NUMBER Ao•s d3. �� PAGE OF_� 068 co c rn o � y c 0 ? 0ul Z ^ p�P W sC Z r N p a N co fit' .-^\ y O N O j O M -d O rU N a ar Y'01 N ^ W r ¢N a YN¢. 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W Q O Q O Q Ln Q Q Q O 0 � 0 �r 0 LG 0 LD 0 m 0 O O Q N a N N co N O M V) M V) V) N cn Q cc F O0 O O ll O O on O O U) O O 4 W Ln Ln Ln Ln N U) U) Cf) .�.i Lu o¢ � (n (n Ln fn (n (n fn m a m <L) a Q < a Q Q Q Q RESOLUTION NUMBER )s �.�• D PAGE OF_. 070 Z z Q Q w o O U U) G Sn aF n w mw g ow m w rz 3 2 r- N U m¢ aw } ?Z U � r mw w = Lo yF ¢ < z z z o 0 0 0 aQ a G O G Y F F Jw > U C U U w w w W U w w N r G¢ Z y N N N Y F {- F d pz ¢2W(nu)<ow- mwt D NW U ¢ LA J Z a QZ F {� a¢ o z oa U,< ua oQ < a < Q a 00 z -.`, N w a w yw, r i i > N > > > zm NN W 'JJ'x 3w w a Z< J GJ¢ GJ¢ O ¢ow G a c ¢ as ZZ Z a OU IL a J¢ N z m ¢C >w z u� Z, ¢v Lu q a ko Ad A a� oR X J tp UU nr ll.l w aa a ¢ Q ¢ ¢ W d uj a N > acc a d a a wo z d W 4 LLJ c^ a (� a z z d cr w U w m z Q a D cc r p o s N a U w � O1 Z Q a ¢.o O H O w O t!} r r < 1 a M Z Q U cn O w d Z o a F- _ w r Q > F- O a O* a CO U. zz O U d 0 In r W 3 N C 1 ) d O O z o z O Z V) � N U Z n w u N N LL N N w w w w w 0- 0 U C�jW W W W W W W W W W W W W LL W o�n a0 m� N N� umi� yQ Nd cc Nq (n �Zx o wZ z U)z Z (nZ NZ Nz NZ o G w U, a a c d a a w a N rn wJw�wzr `'� NDwLL—x t%i ri C1 :¢ W D CD o m O O O h a z O d Z (Wj w f j F Fd id Fa ~ I.- LL cc � 0 a O p p O O n Q a o 0 'pN� w 6 O O � m N F1 f V) (n N C 11 h o o¢ w w w cwia of III 0 N V) UJ V) (n V ¢ H Q$ a < < a a d d d a Q m RESOLUTION NUMBER 60S44 1?3' /0 PAGE OF 071 Tax Rate Type of Corrected R&T Year Parcel No. Area Property Value Section 82-83 503-280-009-5 Land 48319 4985 Imps P.P. City of El Cerrito Change to nontaxable. Cancel penalties. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 82-83 503-280-010-0 Land 48319 4985 Imps P.P. City of E1 Cerrito Change to non-taxable. Cancel penalties. Land Imps P.P. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Land Imps P.P. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Land Imps P.P. 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O Q O Q Q Q Q a O LL Cl) O co 0 M p M p O O O O G d � O u') w U) d -OJ to (n a) m (n ¢ ¢ ¢ ¢ ¢ ¢ o¢ ¢ m M '( ¢ " (n w V) V) Cl) (n (n V1 C N O r0¢ W W W W W W W W W I ¢ U) (n O V) (n (n (n rn m fn f O In (n (n U) O (n 0) V) e Q m a U Q Q a a a Q Q Q RESOLUTION NUMBER �S + �3. /D PAGE OF 073 2 Z 2 e W Ln Ln Ln Lf] In Ln a C) 00 00 OO 00 co 00 p U Q 071 Cil C)1 al Ol Ol C V) �' �' Ica- d' cY V G F p V) W S w w w w w w w owU rl �-/ rl rl rl rl Ow n rz 3 ¢ N N N N N N O H w w w w w w m z (a) O ct GY Wu; w rl rl rl rl rl rl t,w w ¢ N N N N N N r J Q JZ w O O G C O O O O L) r r ti r r U U U U U U U L) U w CW w 2 w w W W w w w w 6 W to W to N N N N to px � �WV)CA¢Crywu r r r r r r r r -¢ wtm m m rt m .e m a NW G Q Q ¢ ¢ Q :]z (7 0Q z r co M M M M M M ° z W 00 co 00 co W `U O Q ��VV �V1I ��N1 I LwjU Z Z ow, a n0 - AO p uW Po ugN w w Zx mw W(D > > > > > > > > a� w OJ Z J J J J J J J J 0f. Z a � W J J J J J J UN ZJ - 7 S >a G O O O O O O O Jd as �, ,U r Q R 6 Q 6 2 Q 6 SZ ¢ou w Jn d a y W JQ w W ,Z ¢, W >w =)> ct %Y GF cY wp ¢W W 1- G a Ct ¢� GQ x J I�C,LU W a ati M M M M M M I!_} ~>aW W a W a W a W a W a W a a a C 3 ¢ 3 3 ¢ 3 ¢ 3 3 ¢ ¢ ¢ � ¢ ¢ w a ¢ < a ¢ $ Q a W o LLI Z a J C J Z Q C Q Q- 0 M w U U) w = D ¢ U J U) Q- > > Q w LL a V, z C Lu F W Q < E 0 4 N ~ 3Z O O w VI VI VI VI N (A r+ V) z 0) v N (1) (1) N H W > O O O O O O W H < a 2 = S 2 S = cr r Z C C C C C C C OLL Q j O O O O O O U Q U U U U U U F- Lu z' Q r c o cr 7 7 7 > > 7 U > a Z fn N fn fn fn N W N N ") W OJ G D W w W W W w W w W w W w W w W W LL azw wa ui wa wa wa wa wa wa O r x V)Z U)Z yZ 0Z yZ y2 NZ V)Z O W C < C) < O < O a O 4 O < < < U) W V) WJw2WZI- Q V)=)LLLL-X , l� Ln M rl 00 tD .4 2 1 I 1 I 1 I 1 rl N M Ln tD Ln m C O C) C) O O r^ o 'a Z C C) C) C C C CU (Wj W N F N ¢ N Q N Q N ¢ Q Q ¢ LL ZIIZ OM QO CD Q. CD Q Q Cl) Q OM Q Q Q Q O to O LL') O V) O Ln O u')Q. D O p C 0 ir O O O O O O O m N y Q O a W V) V) V] V] V] V] V] n w x ~ w V) .w U) V) (n (n V) V) m a m <� a a a�j , a U) a a a a RESOLUTION NUMBER AV 4 F-3• PAGE Y—OF CLAIM �tq BOARD OF SUPERVISORS OF CONTRA COSTA COU"•'PY, CALIFORNIA .BOARD ACTION July 26 , 1983 Claim Against the County, ) NOTE TO CLAIMANT Routing Endorsements, and ) The copy of this document mailed to you is your Board Action. (All Section ) notice of the action taken on your claim by the references are to California ) Board of Supervisors (Paragraph III, below) , Government Code.) ) given pursuant to Government Code Sections 913 & 915.4. Please note the "Warning" below. Claimant: Arthur Reinstein Attorney: Brian D. Thiessen County Caulsal 279 Front St. , P.O. Box 218 2 2 �9a3 Address: Danville , CA 94526 JUN Amount: $5 ,000 .00 + Interest at the Martinez, CA 94553 legal rate. By delivery to Clerk on Date Received: 6/21/83 By mail, postmarked on June 2 0 , 19 8 3 I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted Claim. DATED: 6/21/83 J.R. OLSSON, Clerk, By , Deputy eeni Maltqlto II. FROM: County Counsel TO: Clerk of the Board of Supervisors (Check one only) ( X ) This Claim complies substantially with Sections 910 and 910.2. ( ) This Claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8) . ( ) Claim is not timely filed. Board should reject claim on ground that it was filed late. (§911.2) DATED: G-2 2 JOHN B. CLAUSEN, County Counsel, By , Deputy III). BOARD ORDER By unanimous vote of Supervis6rs pregent (�) This claim is rejected in full. ( ) This claim is rejected in full because it was not presented within the time allowed by law. I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. DATED: J U L 2 6 IJ83 J.R. OISSON, Clerk, by Z_6 , Deputy DARNING (Gov't. C. §913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally delivered or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of any attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. IV. FROM: Clerk of the Board TO: 1) County Counsel, 2) County Administrator Attached are copies of the above Claim. We notified the claimant of the Board's action on this Claim by mailing a copy of this document, and a memo thereof has been filed and endorsed on the Board's copy of this Claim in accordance with Section 29703. DATED: J. R. OISSON, Clerk, by , Deputy V. FROM: 1 County Counsel, 2) County Administrator TO: Clerk of the Board of Supervisors Received copies of this Claim and Board Order. 075 DATED: County Counsel, By County Administrator, By CLAIM 1 C.:AIM -TO: BOAR. )F SUPERVISORS OF CONTRA C 'TA COUNTY Instructions to Claimant A. Claims relating to causes of action for death or for injury to person or to personal property or growing crops must be presented not later than the 100th day after the accrual of the cause of action. Claims relating to any other cause of action must be presented not later than one year after the accrual of the cause of action. (Sec. 911. 2 , Govt. Code) B. Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 106 , County Administration Building, 651 Pine Street, Martinez , California 94553. C. If claim is against a district governed by the Board of Supervisors , rather than the County, the name of the District should be filled in. D. If the claim is against more than one public entity, separate claims must be filed against each public entity. E. Fraud. See penalty for fraudulent claims, Penal Code Sec. 72 at end of this form. ************************************************************************ RE: Claim by ) Reserved for Clerk' s filing stamps Arthur Reinstein Against the COUNTY OF CONTRA COSTA) or DISTRICT) (Fill in name) ) ff The undersigned claimant hereby makes claim against the Conte est a?ntu Costa or the above-named District in the sum of $5400 + le a^} rate. and in support of this claim represents as follows : ------------------------------------------------------------------------ 1 . When did the damage or injury occur? (Give exact date and our The damage occurred on or about May 2 , 1983, at 2 : 30 P.M. ------------------------------------•------------------------------------ 2. Where did the damage or injury occur? (Include city and county) The damaged occurred on Highland Road, Victorine Road and Manning Road. These are portions of Tasajarra Properties located in Contra Costa County. ------------------------------------------------------------------------ 3. How did the damage or injury occur. (Give full details, use extra sheets if required) The damage occurred as a result of road spraying by the Department of Public Works. The weed control spray kills grass and weeds before they grow to the surface, and hence there are insufficient roots to prevent soil erosion. When the soil erodes, the fence posts fall (SEE ATTACHMENT) ------------------------------------------------------------------------ 4 . What particular act or omission on the part of county or district officers , servants or employees caused the injury or damage? Workers responsible for County weed control under the supervision of Jim Baugh, of the County Public Works Department, continue to spray the Claimant 's property improperly. Art Reinstein has repeatedly notified (SEE ATTACHMENT) (over®'7 6 5. -what are the names o,. county or district office- , , servants or . employees causing the damage or injury? Claimant is informed and believes that Jim Baugh is the County Public Works person in charge and responsible for the weed control spraying, which is causing the injury. ------------------------------=---------------------- ----------- 6 . What damage or injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage) One mile of fencing worth a minimum of $5, 000 has been lost as a result of the weed killing spraying. -------------------------------------------------------------------------- 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage. ) The $5, 000 amount that is being claimed for loss of fencing was computed based on inquiry estimates to suppliers who sell fencing. Orchard Supply Hardware Store, (SEE ATTACHMENT) ------------------------------------------------------------------------- 8. Names and addresses of witnesses , doctors and hospitals. Witnesses to the problem include : Peter Banke, 1563 De Soto Way, Livermore, Ca. 94550 Henry Betten court, 9055 Highland Road, Livermore, Ca. 94550 John Leonardini , 2001 Victorine Road, Livermore, Ca. 94550 Vera Reinstein, 8100 Carneal, Livermore, Ca. 94550 ------------------------------------------------------------------------- 9. List the expenditures you made on account of this accident or injury: DATE ' ITEM AMOUNT At this point in time, it would be futile to make expenditures to replace the fencing because the spraying that is causing the damage is continuing. Govt. Code Sec. 910. 2 provides : "The claim signed by the claimant SEND NOTICES TO: (Attorney) or by s m� on his behalf. " Name and Address of Attorney p1``` '� BRIAN D. THIESSEN Arthur insteIn THIESSEN, GAGEN & McCOY Claimant' s Signature Box A Professional Corporation P O Address05 279 Front St. , P.O. Box 218 T.iyPrmflrP, cA 94550 Danville, CA 94526 Telephone No. (415) 837-0585 Telephone No. (415) 449-5216 NOTICE Section 72 of the Penal Code provides : "Every person who, with intent to defraud, presents for allowance or for payment to any state board or officer, or to any county, town, city district, ward or village board or officer, authorized to allow or pay the same if genuine, any false or fraudulent claim, bill , account, voucher, or writing, is guilty of a felony. " 077 Claim by ARTHUR REINSTEIN against the COUNTY OF CONTRA COSTA Attachment ------------------------------------------------------------------------ 3. How did the damage or injury occur? (continued) : down thereby causing the loss of fencing in the area described in question number 1. ------------------------------------------------------------------------ 4 . What particular act or omission on the part of county or district officers , servants or employees caused the injury or damage? (continued) : the County in order to spray when the weeds are high in order to develop the root systems necessary to prevent soil erosion. Jim Baugh has instructed his crews not to spray until weeds are fairly high; nevertheless, spraying has continued in the same areas where fences are being lost. ------------------------------------------------------------------------ 7. How was the amount claimed above computed? (continued) : located at 7884 Dublin Blvd. , in Dublin, Alameda County, estimated the replacement costs to be $ 3, 500 , solely for materials, excluding labor. 078 CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COU1'PY, CALIFORNIA BOARD ACTION Claim Against the County, ) NOTE TO CLADUM July 26 , 1983 Routing Endorsernents, and ) The copy of this document mailed to you is your Board Action. (All Section ) notice of the action taken on your claim by the references are to California ) Board of Supervisors (Paragraph III, below) , Goverrmient Code.) ) given pursuant to Government Code Sections 913 & 915.4. Please note the "Warning" below. Claimant: Marguerite Hickman Count Y (yuunsel Attorney: William J. Hooy 3135 Clayton Road JUN Q 2, 1983 Address: Concord, CA 94519 Martinol, CA 94553 Amount: $30 ,000 .00 Hand Delivered By delivery to Clerk on 6/22/83 Date Received: June 22 , 1983 By mail, postmarked on I. FRDM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted Claim. DATED: 6/22/83 J.R. OLSSON, Clerk, By , Deputy eeni a atto Ii. FROM: County Counsel TO: Clerk of the Board of Supervisors (Check one only) ( x ) This Claim complies substantially with Sections 910 and 910.2. ( ) This Claim FAILS to amply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8) . ( ) Claim is not timely filed. Board should reject claim on ground that it was filed late. (§911.2) DATED: —ZZy JOHN B. CLAUSEN, County Counsel, By , Deputy III. BOARD ORDER By unanimous vote of Supervafors pr sent This claim is rejected in full. LX ( ) This claim is rejected in full because it was not presented within the time allowed by law. I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. /f DATED: JUL 2 ti 083 J.R. OLSSON, Clerk, by �L' �'�, Deputy WARNING (Gov't. C. 5913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally delivered or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of any attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. IV. FROM: Clerk of the Board TO: 1) County Counsel, (2) County Administrator Attached are copies of the above Claim. We notified the claimant of the Board's action on this Claim by mailing a copy of this document, and a mean thereof has been filed and endorsed on the Board's copy of this Claim in accordance with Section 29703. DATED: J. R. OISSON, Clerk, by , Deputy V. FROM: 1) County Counsel, 2 County Administrator TO: Clerk of the Board of Supervisors Received copies of this Claim arra Board Order. DATED: County Counsel, By County Administrator, By. 79 CLAIM CLAIM TO: BOARD • SUPERVISORS OF CONTRA CO 'WYapplicationto: Instructions to Claimant C.erk otthe Board .O.Box 911 Martinez,California 94353 A. Claims relating to causes of action for death or for injury to person or to personal property or growing crops must be presented not later than the 100th day after the accrual of the cause of action. Claims relating to any other cause of action must be presented not later than one year after the accrual of the cause of action. (Sec. 911.2, Govt. Code) B. Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 106, County Administration Building, 651 Pine Street, Martinez, California 94553. C. If claim is against a district governed by the Board of Supervisors, rather than the County, the name of the District should be filled in. D. If the claim is against more than one public entity, separate claims must be filed aaainst each Dublic entity. E. Fraud. See penalty for fraudulent claims, Penal Code Sec. 72 at end tTiis form. RE: Claim by )Reserved for Clerk's filing stamps MARGUERITE HICKMAN F i L E 9. a Against the COUNTY OF CONTRA COSTA) JUiIi aa, IAC ) or DISTRICT) J. R. OLSSON (FillBORD OFn name ) u CONTRA O TAPCOERV�SORS B .....Deputy The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named District in the sum of $3 n nnn and in support of this claim represents as follows: ---------- --------------- ------------ z-------=-------- ---- --- l. When did the damage or in3ury occur? calve exact date and hour] March 23, _1983_ at 5 :0_0 pm _ __ _ _ $, where did the damage or injury occur? ZIncIude city and county) In front of claimant' s residence, 94 A Street, Concord, Calif. 94520 3. -- H ----ow----did--—the----damage-------- or--iin—jury—--occur? Giv------ T--e— —----- �uII detaiis, use extra . sheets if required) Claimant was a passenger in a Contra Costa County Mini bus which brought her home from County Hospital. She required a short stool to exit the bus. The driver of the Contra Costa County Mini bus negligently placed --- the foot stool partially- on the curb and .Partially on the - (see r attached) ---- -- 4. What particular act or omission on the part of county or district officers, servants or employees caused the injury or damage? Negligent placement of foot stool by mini bus driver. (over) (, t 080 • What are the names oaounty or district offices servants or J• employees causing the damage or injury? Mielo Valentin 6. What 8amage or injuries �o you claim resulted? Give full extent of injuries or damages claimed. Attach two estimates for auto damage) Sprained left ankle, knee, hip and back, broken blood vessel in left ankle. The left ankle is a permanent injury, and the other (see attached 7. Howwas th-e--a-m-o-u-n-t--c-l-a-imed above com-p-u-t-e-d--?-- (IInnccllu-dthe-- tm-a-ed --- amount of any prospective injury or damage. ) It is an estimate based upon the severity of the pain, injury and difficulty occasioned the claimant. --------- ----- 8. Names and addresses of witnesses, doctors and hospitals. Doctors: Dr. Ross, Contra Costa_ County. Family Services.., Martinez, CA Treatment was at the Family Practice Clinic, Martinez and at Contra Costa County Hospital. Witnesses: Driver and Claimant. None others known. -- ------------T------------------------------- -----T--------T-T---- IS. LIat the expenditures you made on account of this accident or injury: DATE ITEM AMOUNT To date, plaintiff has incurred only medical services under the Contra Costa County Health Plan and Blue Cross. The costs of such care are not presently known to plaintiff. Govt. Code Sec. 910.2 provides: "The claim signed by the claimant SEND NOTICES TO: (Attorney) or by some person on his behalf. " Name and Address of Attorney If Law Offices of WILLIAM J. HOOY Claimant's Signature 3135 Clayton Road 94 A St. , Concord, CA 94520 Concord, California 94519 it Telephone No. (415) 798-0426 Telephone No. 671-9223 NOTICE Section 72 of the Penal Code provides: "Every person who, with intent to defraud, presents for allowance or for payment to any state board or officer," or to any county, town, city district, ward or village board or officer, authorized to allow or pay , . the same if genuine, any false or fraudulent claim, bill, account, voucher, or writing, is guilty of a felony. " � � 081 ATTACHMENT TO #3 : street, so that it was at an angle and unstable. In addition, the street was wet and slippery at the time. When plaintiff placed her weight on the unstable stool, it slipped, causing her to slip heavily to the ground, severely jarring her body, and causing injury to her neck, back, left.'. 'hip, left side, left ankle and left knee. ATTACHMENT TO #6: injuries are potentially permanent injuries . Al L 082 CLAIM BOARD OF SUPERVISORS OF CDNPRA COSTA COU:TY, CALIFORNIA BOARD ACTION Claim Against the County, ) NOTE TO CLAD1ANT July 26 , 1983 Routing Endorsements, and ) The copy of this document mailed to you is your Board Action. (All Section ) notice of the action taken on your claim by the references are to California ) Board of Supervisors (Paragraph III, below) , Government Code.) ) given pursuant to Government Code Sections 913 & 915.4. Please note the "Warning" below. Claimant: Edward F. $ Patricia A. Sullivan Attorney: Rodney A. Marraccini , Esq . 1280 Boulevard Way, Suite 202 Address: Walnut Creek, CA 94595 + Amount: $252 ,520 .00 i By delivery to Clerk on � Date Received: June 201983 By mail, postmarked on 6/17/83 Certified P 264 190 686 I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted Claim. 0p JUN 2 2 1983 DATED: 6/20/83 J.R. OLSSON, Clerk, By�rnCL�Ca �� 94553 Reeni Mal to II. FROM: County Counsel TO: Clerk of the Board of Supervisors (Check one only) (X ) This Claim ccu plies substantially with Sections 910 and 910.2. ( ) This Claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8) . ( ) Claim is not timely filed. Board should reject claim on ground that it was filed late. (§911.2) DATED: JOHN B. CLAUSEN, County Counsel, By Deputy III. BOARD ORDER By unanimous vote of Superviabrs present ( ) This claim is rejected in full. ( ) This claim is rejected in full because it was not presented within the time allowed by law. I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. DATED: `JUL 2 S l 1581 J.R. OISSON, Clerk, by , Deputy WARNING (Gov't. C. 5913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally delivered or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of any attorney of your choice in connection with this matter. If iou want to consult an attorney, you should do so immediately. IV. FROM: Clerk of the Board TO: 1) County Counsel, 2) County Administrator Attached are copies of the above Claim. We notified the claimant of the Board's action on this Claim by mailing a copy of this document, and a memo thereof has been filed and endorsed on the Board's copy of this Claim in accordance with Section 29703. DATED: J. R. OISSON, Clerk, by , Deputy V. FROM: ) County Counsel, 2) County MM-Arstrator 70: Clerk of the Board of Supervisors Received copies of this Claim arra Board Order. / DATED: County Counsel, By 3 County Administrator, CLAIM ,F .,Fe-,, D CLAIM AGAINST COUNTY OF CONTRA COST b JUli �,)o, 193 To; COUNTY OF CONTRA COSTA j. R. OLFoQN Attention: County Clerk t cap 2D AP p 4R 725 Court Street DeO� Martinez, CA 94553 Pursuant to Section 910 of the California Government Code, claim is presented to the County of Contra Costa, California, as follows: (a) The name and post office address of the claimants: Edward F. and Patricia Ann Sullivan 621 Adobe Drive Danville, CA 94526 (b) The post office address to which the persons presenting this claim desire notice to be sent: Rodney A. Marraccini, Esq. Law Offices of Rodney A. Marraccini 1280 Boulevard Way, Suite 202 Walnut Creek, CA 94595 (c) The date, place, time, location and other circumstances of the occurrence or transaction which gave rise to the claim asserted: Date: March 23, 1983 Time: 1:03 p.m. Place: Intersection of Adobe Drive and Woodbine Lane, Danville, Contra Costa County, California ; Circumstances: Kevin Michael Sullivan, 4-year-old son of claimants, was struck and killed by an automobile in the said Intersection. Said intersection constituted a dangerous condition of public property which was the cause of Kevin' s { wrongful death, in that said intersection was defectively designed and negligently inspected and there was failure to discharge a mandatory duty to inspect works for which a permit was required, failure to enforce ordinances after notice of their violation, and failure to control the intersection with traffic control devices. (d) A general description of the indebtedness, obligation, injury, damage or loss incurred so far as it may be known at the time of presentation of the claim: Wrongful death of claimants' son, Kevin Michael Sullivan; medical and incidental expenses; funeral expenses. 084 CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COLP.'TY, CALIFORNIA BOARD ACTION Claim Against the County, ) NOTE TO L7AU1ANT July ;ZO,, 1983 Routing Endorsements, and ) The copy of this document mailed to you is your Board Action. (All Section ) notice of the action taken on your claim by the references are to California . ) Board of Supervisors (Paragraph III, below) ,' Goverrunent Code.) ) given pursuant to Government Code Sections 913 & 915.4. Please note the "Warning" below. Claimant: Thomas Edwin Groff, a Minor, By Adrian Bryce, 'Guardian ad Litem Attorney: Ladue & Goldston 319A Lennon Lane Address: Walnut Creek, California 94598 Amount: Unspecified Packet delivered May 27 , 1983 By delivery to Clerk on Date Received: Board granted applicationBY mail, postmarked on on June 28- 1983 I. FROM: Clerk of the Board of Supervisors TO: County CourEV COORSOl Attached is a copy of the above-noted Claim 0 1 1983 DATED: June 28 . 1983r•R. OLSSON, Clerk, r _ g53 Kellv R. Calhoun II. FROM: County Counsel TO: Clerk of the Board of Supervisors (Check one only) ( ) This Claim oomplies substantially with Sections 910 and 910.2. (}( ) This Claim FAILS to amply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8) . ( ) Claim is not timely filed. Board should reject claim on ground that it was filed late. (§911.2) DATED: - JOHN B. CLAUSEN, County Counsel, By , Deputy III. BOARD ORDER By unanimous vote of Supervisors p ent (V) This claim is rejected in full. ( ) This claim is rejected in full because it was not presented within the time allowed by law. I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. DATED: JUL 2 6 1983 J.R. OLSSON, Clerk, by Deputy WARNING (Gov't. C. §913) Subject to certain exceptions, you have only six (6) months frcm the date this notice was personally delivered or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of any attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. IV. FROM: Clerk of the Board TO: 1) County Counsel, 2) County Administrator Attached are copies of the above Claim. We notified the claimant of the Board's action on this Claim by mailing a copy of this document, and a memo thereof has been filed and endorsed on the Board's copy of this Claim in accordance with Section 29703. DATED: J. R. OLSSON, Clerk, by , Deputy V. FROM: 1) County Counsel, 2 County Administrator TO: Clerk of the Board of Supervisors Received copies of this Claim and Board Order. 08 6 DATED: County Counsel, By County Administrator, eXH1F31 T A 1 LADUE & GOLDSTON 319A Lennon Lane 2 Walnut Creek, California 94598 Telephone: ( 415) 930-6380 3 Attorney for Claimant 4 5 6 7 In the natter of the Claim of: ) APPLICATION TO FILE CLAIM AGAINST PUBLIC ENTITY 8 THOMAS EDWIN GROFF, a ) Minor, by ADRIAN BRYCE, ) 9 his Guardian ad Litem , ) 10 Claimant, L E DF 11 VS . ) JUP!e?Y fig? 12 COUNTY OF CONTRA COSTA , ) . J. R. OLSSON a Public Entity. ) CLERK BOARD OF SUPERVISORS 13 B 14 15 TO : COUNTY OF CONTRA COSTA : 16 Thomas E. Groff hereby makes claim against The County of 17 Contra Costa for a sum which cannot be determined at this 18 time and makes the following statements in support of the claim : 19 1 . Claimant' s post office address is 1443D Marclair 20 Street, Concord, California. 21 2. Notices concerning the claim should be sent to 319A 22 Lennon Lane, Walnut Creek, California 94598. 23 3. The circumstances which gave rise to this claim are 24 as follows . On or about December 16, 1981 , claimant was 25 committed to the custody and jurisdiction of the Contra Costa 26 County Juvenile Court and Contra Costa County Social Services 27 Department. It was determined by those agencies that 28 claimant should be placed in a group home. Claimant was -1 - 1 i 087 I accepted and enrolled in Family Life Center upon the 2 recommendation of the above-named county agencies, an 3 entity which is subject to the control and supervision of 4 the County of Sonoma and is an approved group home deemed 5 fit for residence by wards and dependents of Contra Costa 6 County. 7 On June 15, 1982, claimant was in the custody and care 8 of Family Life Center, located at 3478 Bodega Avenue, 9 Petaluma, California. Claimant was on the grounds of the 10 group home and was engaging in unsupervised activity with 11 other residents of the group home when he fell from a "tree 12 fort" , 20 feet or more to the ground. As a result of the 13 fall, claimant suffered severe injuries which were further 14 agitated by improperly rendering first aid and handling 15 administered by employees of the group home. 16 4. Claimant' s injuries are a broken back and internal 17 injuries . 18 5. The names of the ublic employees causing the claimant' s 19 injuries are unknown > at this time . 20 6. The amount of my claim as of the date of this claim 21 is not yet determined. 22 Dated: May 27, 1983 23 24 Debbi A . Goldston 25 On Behalf of Claimant 26 27 28 -2- 088 1 EXHIBIT B 2 DECLARATION OF ADRIAN BRYCE 3 I , Adrian Bryce, declare as follows: 4 I am the mother of Thomas Edwin Groff, Jr. , the-:claimant 5 herein and his guardian ad litem for purposes of this claim . 6 The Claimant was born on March 29 , 1966 and on the date of the 7 incident upon which the claim is based, he was 16 years old. 8 He was a minor for 100 days following theJune 15, 1982 incident 9 and is currently a minor. 10 I declare under penalty of perjury that the foregoing is 11 true and correct, and that this declaration was executed on 12 May 24, 1983, at Walnut Creek, California. 13 A_ 2 14 �-- Adrian Bryce 15 16 17 18 19 20 21 22 23 24 25 26 27 28 089 CLAIM / BOARD OF SUPERVISORS OF CONTRA COSTA COU."My. CALIFORNIA BOARD ACTION Claim Against the County, ) NOTE TO CLAIMANT July 26 , 1983 Routing Endorsements, and ) The copy of this document mailed to you is your Board Action. (All Section ) notice of the action taken on your claim by the references are to California . ) Board of Supervisors (Paragraph III, below) , Government Code.) ) given pursuant to Government Code Sections 913 & 915.4. Please note the "Warning" below. Claimant: Clarence William Henry Attorney; Kletz $ Moll S315 College Ave . Address: Oakland, CA 94618 Amount: $120009000 .00 By delivery to Clerk on Date Received: June 20 , 1983 By mail, postmarked on June 19 , 1983 I. FROM: Clerk of the Board of Supervisors TO: County Counsel ""'Y u4unsel Attached is a copy of the above-noted Claim. - ' o JUN 2 2 1883 DATED: 6/20/83 J.R. OISSON, Clerk, a5ion 94553 eeni Mal to II. FROM: County Counsel TO: Clerk of the Board of Supervisors (Check one only) (X This Claim ccniplies substantially with Sections 910 and 910.2. ( ) This Claim FAILS to amply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8) . ( ) Claim is not timely filed. Board should reject claim on ground that it was filed late. (§911.2) DATED: (, -Z z JOHN B. CLAUSEN, County Counsel, , Deputy III. BOARD ORDER By unanimous vote of Supervisors preAnt (u) This claim is rejected in full. ( ) This claim is rejected in full because it was not presented within the time allowed by law. I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. DATED: J U L 2 6 1983 J.R. OLSSON, Clerk, by , Deputy MU NTNG (Gov't. C. §913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally delivered or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of any attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. IV. FROM: Clerk of the Board TO: 1) County Counsel, 2) County Administrator Attached are copies of the above Claim. We notified the claimant of the Board's action on this Claim by mailing a copy of this document, and a memo thereof has been filed and endorsed on the Board's copy of this Claim in accordance with Section 29703. DATED: J. R. OISSON, Clerk, by Deputy V. FROM: 1 County Counsel, 2) County Administrator TO: Clerk of the Board of Supervisors Received copies of this Claim and Board Order. 090 DATED: County Counsel, By County Administrator, By CTAIM • FS Fm D ,2°, 1983 CONTRA CO . R. OLSSON ARD O� SUPERVISORSCLAI;1 AGAINST fI(E ? ix r COUITTY OF XXXXF-WIT CosTTC e ut Charter Section 87 and Government Code Sections 910 to 911. 2 require that all claims must be presented to the Controller or to the Clerk of the Board of Supervisors within 100 days from date of accident or incident. CLAIMANTtS NAME CLARENCE WILLIAM HENRY c/o Law Offices of Kletz & Moll CLAINA1,TT' S ADDRESS 5315 College Avenue TIM12, HONE (415) 655-7141 Oakland, CA 94618 AMOUNT OF CLAIM 1 .000,000. 00 ADDRESS TO WHICH NOTICyS ARE TO BE S `TT c/o Law offices of Kletz & Moll, 5315 College Avenue, Oakland, CA 94618 DATE OF INCIDENT March 22, 1983 LOCATION OF INCID ZJT Moraga Way/Orchard Road. Unincorporated, Contra Costa County HOW DID IT OCCUR Claimant was struck by a vehicle while a pedestrian on an unlit roadway DESCRIBE DA?iAGL•' OR INJURY To date: loss of one leg, numerous other injuries NAM OF PUBLIC a1iLOYEE(S) CAUSING INJURY OR DAMAGE, IF KNOWN unknown ITc"IMIZATION OF CLAIII (List items totaling amount set forth above) Hospitalization unknown Wages $ unknown Loss of future income unknown Pain and suffering $ unknown Other � $ unknown TOTAL $ Signed by or or. behalf of Claimant HARVEX,10M. KLETZ Dated: -44tRp',. �, �7�3 Attorney for Cla mant -- _... _. .. -0 9 1 . . .BOARD ACTION //jam July 2�, 1983 CLAIM • BOARD OF SUPERVISORS OF CCNTRA COSTA CW:TY, CALIFORNIA BOARD ACTION Claim Against the County, ) NOTE TO CLAIMANT Routing Endorsements, and ) The copy of this document mailed to you is your Board Action. (All Section ) notice of the action taken on your claim by the references are to California ) Board of Supervisors (Paragraph III, below) , Government Code.) ) given pursuant to Government Code Sections 913 & 915.4. Please note the "Warning" below. Claimant: Dona Brooke Phillipy 2130 Ramona Drive Attorney: Concord, CA Address: Amount: $518 . 73 By delivery to Clerk on Date Received: .June 24, 1983 By mail, postmarked on ,lune 22 . 1983 I. FROM: Clerk of the Board of Supervisors TO: County Counsel Coui* Counsol Attached is a copy of the above-noted Claim. JUN 2 8 1983 DATED: lime 741 9R 4T.R. OLSSON, Clerk, By^ "�a MCA 94553 Kell. Calhoun II. FROM: County Counsel T0: Clerk of the Board of Supervisors (Check one only) ( X ) This Claim complies substantially with Sections 910 and 910.2. ( ) This Claim FAILS to oomply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (section 910.8) . ( ) Claim is not timely filed. Board should reject claim on ground that it was filed late. (§911.2) DATED: - JOHN B. CLAUSEN, County Counsel, By Deputy III. BOARD ORDER By unanimous vote of SuperyYsors prifsent ( This claim is rejected in full. ( ) This claim is rejected in full because it was not presented within the time allowed by law. I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. DATED: JUL 2 6 1983 1.R. OLSSON, clerk, bPZ4 Deputy SING (Gov't. C. §913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally delivered or deposited in the mail to file a.eourt action on this claim. See Government Code Section 945.6. You may seek the advice of any attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so mediately. IV. FROM: Clerk of the Board T0: 1) County Counsel, 2 County Administrator Attached are copies of the above Claim. We notified the claimant of the Board's action on this Claim by mailing a copy of this document, and a memo thereof has been filed and endorsed on the Board's copy of this Claim in accordance with Section 29703. DATED: J. R. OLSSON, Clerk, by Deputy 092 r CLAIM TO: BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY Instructions to Claimant A. Claims relating to causes of action for death or for injury to person or to personal property or growing crops must be presented not later than the 100th day after the accrual of the cause of action. Claims relating to any other cause of action must be presented not later than one year after the accrual of the cause of action. (Sec. 911. 2, Govt. Code) B. Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 106 , County Administration Building, 651 Pine Street, Martinez , CA 94553 (.or mail. to P, 0, Box 911, Martinez , CA) C. If claim is against a district governed by the Board of Supervisors , rather than the County, the name of the District should be filled in. D. If the claim is against more than one public entity, separate claims must be filed against each public entity. E. Fraud. See penalty for fraudulent claims, Penal Code Sec. 72 at end of this form. ********************************************** ***** RE: Claim by /. ) Resery folCtk' stamps a. Eb ( ('' P42 � f J04, V Jury 241983 ) Against the COUNTY OF CONTRA COSTA) J. R. OLSSON CLER AR OE SUKRVISORS NT Co CO. or DISTRICT) By.. �.._ .... . .. .0P—UTLJ Fill in name) ) The undersigned claimant hereby makes claim against the Caunty of Contra Costa or the above-named District in the sum of $ `; �� and in support of this claim represents as follows: - --------------------------------------------------- 1-.---When-----did----the----da--=m g orry occur? (Give exact date and hour) ��� 4 -------------- --------- --------------------------- 2. Where did the damage or injury occur? (Include city and county) 3. How did th�damag(�or injury_4r? (Give full details, use ext sheets If rei uir,e ) �%'C� Aa �t UC'� ` �2�{ C'0Y j'10 4 What articular act or omisson onjhe part of aunty or district officers , servants or employees caused the injury or damage? � /u� �C ' v C,JJ z�:tC /A, I � " 093 • 5.. 467hat =are the names of county or -district ecrfficers., servants lir ,employees ,causing t:he damage or Injury? al bclaim fesulted? ,(Gi . What .damage or injuries do you ve full extent of injuries or damages claimed. Attach two estimates for .auto damage) 7, ow was the amount laimed above computed? (Include-Vhe estimated amount of any prospective injury or damage. )., 8. Names and addresses of witnesses, doctors and hospitals. 40 ----- ------z----------------------------------------------------- �L 9. List the expenditures you made on account of this accident or injury: DATE ITEM AMOUNT Govt. Code Sec. 910.2 provides : "The claim signed by the claimant SEND NOTICES TO: (Attorney) or by some e n on his behalf. " Name and Address of Attorney Clavl,,m4 nt Is Si e Address Telephone No. Telephone No. (27/- 69J / NOTICE Section 72 of the Penal Code provides: "Every person who, with intent to- defraud,- presents for allowance or for payment to any state board or officer, or to any county,, town, city district, ward or village board or officer, authorized to allow or pay the same if genuine,. any false or fraudulent claim, bill, account , voucher, or writing, is guilty of a felony. " 094 1 BILL'S BODY AND PAINT 1800-8 CONCORD AVENUE, CONCORD, CALIFORNIA 94520 TELEPHONE 415-7984161 G - oer. y , _ NAME �/� ADDWESS Cm PHONE make � � dql r..r�t�.rrieml No. Body Stvio style No. mite". License Nom,( u -►NM No. Trim No. Ineurenee Co 69PAIR MUKAW ESTIMATE OF REPAIR COSTS MBR PARTS SUBLET �✓ 51 A/045 c l f Ji �s TOTAL RttrAR/ul � f`MONS. or u6ow •!-� PtR Mw. 4i .ARTS PAINT MAT t RI ALS ! � INSUR ANGt OtOUC TIBLt SUBLCT •r, lALtS TAIL TWO• tST1MAT4 IS SASSO ON cue INSPt071e11 ANO 0098 NOT 61OW611 ADDITIONAL PARTS OR 60141041 WHICH MAT SL 1190VIS60 ArTtR 7Mt WORK HAS 599M 11TADTite. A/TCO TML tlTIMA TL TOTAL ! most HAS •f AK7i0. WONN OR OAMAStO shs/e WHf CH Ast NOT tyillt%? on rise? IN. 009CTION MAT et OISCovgmgD. NATURALLY. THIS tSTIMATt CANNOT SOTtR SVCN t ONTINetNCl9S. PARTS MlCi/ sUSJec? TO C1YN! WITNWT movies. 71116 YTIMATt AOWANCt CMAROtS S IS Pon 14"961^741 Adca"ANCt. ESTIMATE INVALID AFTER 30 OAVS. Q TOTAL PARTS PRICES SUBJECT TO INVOICE" U J CUSTOM AUTO PAINTING TELEPHONE 896117 JIM MALTSfEE 1548 GALINDO STREET - CONCORD, CALIFORNIA 94520 DREG L 61 „ ,um pp/ �i jw= Cm . K Make ry Year. 1�\�) SerialNo. —Prod.Date — Mileage Mileage_~License N Botly Style � n_-,-Insurance Co. [PAIR REPLACE LABOR PAINT ESTIMATE OF REPAIR HRS. PARTS TIME - SUBLET Ra ,ti 7 b.4 eL- L S T TOTAL R FMA RKSI 9 /1. MRS. OF LASOR f SI7(/ PER MR 2L PARTS PAINT MATERIALS S S INSURANCE DEDUCTIBLE SUBLET BTI SALES TAX l THIS ESTIMATE IS SASSO ON OUR INSPECTION AND DOES NOT COVEN ADDITIONAL PARTS 6(� OR LAeon WHICH MAY EE AEDU INC0 AFTER THE WORN WAS ECLM STARTED. AFTER THE ESTIMATE TOTAL 3 WORN HAS 2TARTEO. WORM OR DAMAGED FARTS WHICH ARE NOT LVIOENT ON FIRST IN• 1PEC TION MAY SE DISCOVERED. NATURALLY. THIS ESTIMATE CANNOT COVER SUCH CONTINGEM C I IS. PARTS PRICES SUSJECT TO CHANGE WITHOUT NOTICE. THIS ESTIMATE ADVANCE CHARGES S IS FOR IMMEDIATE ACCEPTANCE. THIS WORK AUTHORIZED By '1 GRANO TOTAL S 096 CLAIM t k. BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFIORNIA BOARD ACTION Claim Against the County, ) NOTE TO CLAIMANT July 26, 1983 Routing Endorsements, and ) The copy of this document mailed to you is your Board Action. (All Section ) notice of the action taken on your claim by the references are to California ) Board of Supervisors (Paragraph III, below) , Government Code.) ) given pursuant to Government Code Sections 913 & 915.4. Please note the "Warning" below. Claimant: Cadillac Ambulance Service, Inc . Attorney: Gary Hursh 1 +25 River Park Dr. #350 Address: Sacramento, CA 95815 Amount: Unspecified Hand Delivered By delivery to Clerk on 7 m e 21 1 9 8 3 Date Received: June 21, 1983 By mail, postmarked on I. FROM: Clerk of the Board of Supervisors TO: County CounselCOUi-lty Counsel Attached is a copy of the above-noted Claim. JUN 2 9 1983 DATED: 6/21/81 J.R. OLSSON, Clerk, By,, cr t��-�f� it ardW.1W 94553 'Reeni Ma tgtto II. FROM: County Counsel TO: Clerk of the Board of. Supervisors (Check one only) ( ) This Claim complies substantially with Sections 910 and 910.2. ( ) This Claim FAILS to ccuply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8) . ( ) Claim is not timely filed. Board should reject claim on ground that it was filed late. (§911.2) DATED: G - Z9 —bJOHN B. CLAUSEN, County Counsel, By , Deputy III. BOARD ORDER By unanimous vote of Superyksors pretent ( This claim is rejected in full. ( ) This claim is rejected in full because it was not presented within the time allowed by law. I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. DATED: JUL 2 6 1983 J.R. OLSSON, Clerk, byEd Deputy. MUNING (Gov't. C. §913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally delivered or deposited in the mail to file a court action on this claim. See Coverrmient Code Section 945.6. You may seek the advice of any attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. IV. FROM: Clerk of the Board TO: 1) County Counsel, 2) County Administrator Attached are copies of the above Claim. We notified the claimant of the Board's action on this Claim by mailing a copy of this document, and a memo thereof has been filed and endorsed on the Board's copy of this Claim in accordance with Section 29703. DATED: J. R. OLSSON, Clerk, by , Deputy V. FROM: 1) County Counsel, 2 County Administrator TO: Clerk of the Board of Supervisors Received copies of this Claim and Board Order. 097 DATED: County Counsel, By County Administrator, By. CLAIM CLAIM TO: BOARD • SUPERVISORS OF CONTRA CO& COUNTY Instructions to Claimant n '1 A. Claims relating to causes of action for death or for injury to person or to personal property or growing crops must be presented not later than the 100th day after the accrual of the cause of action. Claims relating to any other cause of action must be presented not later than one year after the accrual of the cause of action. (Sec. 911. 2, Govt. Code) B. Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 106, County Administration Building, 651 Pine Street, Martinez , CA 94553 (Or Anil. to P. Q. Box 911, Martinez, CA) C. If claim is against a district governed by the Board of Supervisors, rather than the County, the name of the District should be filled in. D. If the claim is against more than one public entity, separate claims must be filed against each public entity. E. Fraud. See penalty for fraudulent claims, Penal Code Sec. 72 at end of this form. RE: Claim by )Reserved for Clerk's filing stamps Cadillac Ambulance Service, Inca LED] Against the COUNTY OF CONTRA COSTA) JURI 1J or DISTRICT) J• R. OLSSON BOARD OF UPERVISO (Fill in name ) o. [Crin ..... . uty pyty The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named District in the sum of $ and in support of this claim represents as follows: U__ ——-- RR ——- -----------------I— -----—----- -----—--------—---——------— --— 1. When did thdamage or injury occur. (Give exact date and hour] Within the last year. See attached. 2. Where did tFie damage or injury occur? Include city and county) County of Contra Costa 3. How did the damage or injury occur? (Give full details, use extra sheets if required) Failure of the county to pay for indigents and ambulance transports from a county designated or county facility . Contra Costa County Contract No . 22-079-8 ------ ------------------------------------------------- ----------------- 4. What particular act or omission on the part of county or district officers, servants or employees caused the injury or daiaage? Refusal to pay. 5. What are the Games* c+cxsnty or 41istri t Off es, servamts or amplcayoes varasiaq the damage or injury? Department, of Health Services �. What damage or injuries do you claim resultea7'ZG.ive full extent of injuries or damages claimed. Attach two estimates for auto damage) According to proof ---- - -- ---- a------- --H-ow--was--th--e amoumimed ------------- estimated amount of any prospective injury or damage. ) According to proof ------------------------------------------------------------------------- 8. Names and addresses of witnesses, doctors and hospitals. Paula Hines , E .M. S. Director 9. List the expenditures you made on account of this accident or injury: DATE ITEM AMOUNT According to Proof Govt. Code Sep. 910.2 provides: "The claim s '' ned by the claimant SEND NOTICES TO: (Attorney) or some son 0 his behal . ' Name and Address of Attorney -4, k�V& &5:Z�t2 1a m n s Signatur Gary Hursh Attorney at Law 460{ Nevin {ve 1425 River Park Dr #350 Sacramento , CA 95815 RichAMestA 94805 Telephone No. (916) 929-1084 Telephone No. Psi OBO NOTICE Section 72 of the Penal Code provides: t "Every person who, with intent to defraud, presents for allowance or for payment to any state board or officer, or to any county, town, city district, ward or village board or officer; authorized to allow or pay the same if genuine, any false or fraudulent claim, bill, account, voucher, or writing, is guilty of a felony. " 099 • ��� =it If' 1i DEMAND N0. 192 VENDOR N0. I)L:A1,1 CE COP,6• the TTeuswy nt Ilte . -_-�' COUNTY 70 COS I'A Presented By: STATE OFCALIfIiRNt'A' ,,_ ; DATE MAY 4. 1982 CADILLAC AMBULANCE SERVICE, INC. MSM[ ILAST) (FIRST) IMPORTANT 4601 NEVIN AVENUE See instructions on Reverse Side ADDRESS RICHMOND, CA -94805 CONTRACT # 22-079-8 CITY, [TAT[ .ZIP C00[ DATE: 7-1-81 to 6-30-52 I I I I I I I—,I] IIggL , too . For the sum of ***()NF THOUSAND NINE HUNDRED FORTY TWO AND 20/100******* Dollars $ -' , As itemized below: UNCOLL CTIBLE'S DATE DESCRIPTION AMOUNT �F _ C _ -_SEE ATTACHEDRECEIVED ' Ig �---- ----h1AY 7 198?_ �— PAIS Me:! Ererrerc7ical Se1Vi:e9 �-- -- ---- __ ._- - ----- _.�._!k ,rl�..lk___��'tvn�r� ..cu��lGt/cc _�1tCc�r_,lTTic:��'.�� �- --• - r '....,., C► -_ q^7 f r^•�"ty'laeira service. /� y,� /9L5y'i-/��=� ZZL _L�_z�J •? �� tt �;►^��Iifa,sc,w."•s - - ----- —REt'€tYE�tT— . -i -- �953.� o - 76 1- - < - —lsIAX-20 1382- Thr nademigned under the penalty of perjury states: That the above clalra and the items as therein Set o•'t ;ere true and corr-o: 'hat nd part thereof has been heretofore paid, and that the amount therein is justl�( dale., and that tye -Ame is presented within one Year after the last item thereof has ac erued, jy signet' VENDOR No. Received, Accepted , and Expenditure Authorized - OtAAI!TYr.NT OvArl on CNI}1' CLRUT}'. YvY1iS '"t-N1.O i'f —=I f C U M 0 6,111 N of N O �C ►xt Y M T AM PAT ITJl �e J 11�}�. r 57NT1 VI C TI G (VITT Crtc •lel. cis LUN%NO. lMVO,C[ Dl7[ D![CNV7lON FUND/One. ACLOUNT fNCU1pANCL NO NC ►AY Y[N7 AMOUNT =XsL '>TtA[ - OgCOUMT I , lUY \O. INYOI� OC NCRI�OM rUNJ UR••.-�ytACCLUYt [NC LY[R ANLL MO I C PIVYI MT AMOUNT L , TAXAUL[ AUOCnT tA[X OI TION /G T,V ITT VtC ?LOSOyt�y!}Tt (DIS RIV. 7/77) aCQNTi#AfLOST OUNTY.,.PRE`NO$P,,ITAL.CARE �tEP T I ,{,��;b � Q� �i iii i tr ".L. � ) .`+ - y,7�t{i.,,�"ik ify ♦• , r r.:n,f - t? ''a�,f•.1 nrr {G a DISPATCH INFORMATION}rk; 1 rj` rte' TIME.(24 HOUR L CK w' �',MILEA 1 ' IN lo..'a,T 1 'I:` M 1S�C .. ..i.t - .z i �.} , ,' Mri,TORE OF PROBLEM! 1 t ' +i x Call Received 1 S , End �✓ . 1 hoe r,i. `y tri ," d, an s:Y 4. r 1J ,,(as dfspetched) 1�f Ll (�)CMZ( Tf�f1�S�to Time 10$ a i ti Ste INCIDENT LOCATION : rr x131 4 d .9S, jr;C v �.' ii� L yv 1, q4z .fi':I k ttsl o h < .a(�Q ( .6 9 6�. 5 � +•r .. �r ,.'��'. , t.�TImeF1 O'87 w 'zt�. r yF7.I Ot81 a sL ,Address ( �K- TI ie10A8 \,si RESPONSEC a w i P,;A F4, r. ,• if s*'ta 2+� f,bA.r a'R d':e..t.`1 `Ct(y t Cross St �Tfine 10-7a To scene` CA Back Back No ; 1} `I H ,Itl°. Time 104)874 1 « r a, .} yfk'. I R Q S Fj ❑PSD ro Q PS+�P t ,,j., .{ r•'' q" ,, "' •\ ' �j. i: f From:scene $LBndby.T ma r. ,,, , 3��.7',/1/ a !, ..r•.y�. PATIENT DESTINATION txi CBnceileB it az', y �•i J �,} i 'a x; t' R� r IIoW.Cho;en Dry(tun:;s QXesjj No, ' Ll Nearest f's ily r A ❑Transfer 8 Reesor?.torDry Run r. +"? ' XII Patient Q Dvett Admit ,e .'t,•S L70thel y a fy,,Aus4{iLlrationfor O Run(EMS Usa Onlyl��` s ,ar��r'iy: 4 {x;.!'FII Ty Un(t No PATIENT/BILLING.)NFORMATION parpmedi, t y ^'Unit No G aU nt`'`Neme - Dever . . ? c .► °>#i% + , a'" ' •'Ti' a Attendants �'+� `4 ''�:kiZ• Y �t ►y L Iv7iY^K`ylWf Dispatcher Address ype o , ronspo mbulence heeicheir/Ca ' 4 W + • r ), { �{ ; ylence Company ar y:; C�ty )�+ � St>}te ^ :tr ' ip rQAntioch�lk', rope F re RESPONSE ZONE Phone:, t SS;Nog F =k :Cadillac t�[3PomeroYI (a`t.it4;,r�•,ly{t *4 ' 13 East C • TriC7ties''py•. '` "b,S ;QG Occu tion , ,7 V ',y M , Q 1Ya \ ,y_ , , , r Sf` ❑Micljaels ❑ValleyFiro r� N ❑9 >� 0 $�PMD aT MD.— #. ''Q' fll ;s,,j1ttFk' `' ^ry, the.�Physkien^� ' h `�� ��i�• �F i�`�vM,jDt� ��r ' ��tyr���fi�'%ttr �� � ,�4�' '�/.# RESPONSIBLE PPA\RTY' ?c`�.,T,,* ��'' i, f`l .ia7".T I _ F wrya '�•-�'•�sf�;i '1iG. �'/'j+t.kk i�}' S6ese.Rate (I pt.) �a--�=�• a'. �N h l+�„ 'f fit (1 of R et nthip ip„, a 4K i c, '.tsii. j .��L po).i '_'_M1 l'of 3 pti�l MTf r m p 'ti3 ,nli' fa` 0�� ((3R'�''7t1 � 'AddreSa "a 4).5 f,a' �r}z•...1 r 1: x. `? Total Miles ° .'i .�, Ci x 1 e .' n�zx° State' r s'21p j� Yf1i0Und.Tri r Wr k i Y; r f' a rof a4: t��liTe .R.s'�i `'\ ".F� a... ��§ 2;`✓1},1'a!i S k,�`.i tyw�liay. a ' P 1E, i «t . Vf Phone $ �> Dceu atl ' { Q Yef ❑NO 1' S't cR s at,} Night.(7:00 P m % 00 a.m., Work Phoned Employer ', Emergency Run _' + f u � t i i' r" } • , y / } rCode 2 i, ✓� ' ? s a34hG; r 1 r,���e Address t r je w.{\ • h , �. �i cP �yy.�,��+'��e€r? yt Y' .i.� l..r. r i • w !y Mi'M x�q•�.� .Q COdB3 ' N� r?, rraa`"tr'`'��r;•�� rf'i, � �•tiF , 1'" - City State: 'OxVgen(Per Tank).• �+ X ' 1a )g 7S ; SrSNeonatal (incubator )f "�•,+.t , :.:c•K'.dy'; ypa' •'; ,• MEDICAL COVERAGE :7 w•'-INDUSTRIAL 13 Yes ►LxNo I? f` j �t y� wc` � w� Y i•_\f. S.- 1 a \ , , " 'A ''tff Standby(Over 15 min) ,4'aiv.r i-r �. .•( M + ' Private Ins Co ' EKG(Per episode).i f' " 1r a7 ' ,T"+1:, -t e , .�. t a Sa Ajt ,t�t;; \ t tyi l�l}'oaf v'1+ay.Y' S�"t'( S•�.' .�1 , F'rIJ (per admin.) x r K81a8f No.: g pe Drugs redminJ._..�X , it rl iw BIUA Cross I�o', '�.,j.EOA�(if not replaced) Orel Airway(if not replaced) {Fr Medicare No ti� �� -S^�_ E.O M.B.Attached L+. ITC-0oilar(if not replaced) r Q Yes .<Q No i t t,,Dry Run(authorized) < CCHP No Ig'3 C yD ICaI No.: ; tA�. ai :s iQ , '•✓ ,+, tS Lr lYA r 5 :z POE Sticker es14 It QNo En yf: eq- 1 Dates Billed: + i�•i TOtel i 60 t i y' ` Y.2i. S.S'!t� t^. AMBULANCE `TRA, COSTA COUNTY PRE-HOSPITAL CARE' FORM I . ', UNIT c� AUT�IZATIOw / I•r CHECK OR iZLL N APPROPRIATE SPACES :+., DATE: -w1: { y 'IMM'S NAME M F " COMPANY )RESS _e GE >4 t'Y` tiC .� STATE ZIP L -D B U QSn OK �1 t.k't tVER°S LICENSE 0 PHONE -2 p NATURE OF DI ATCH ""' • ' ' :." ' E OF TRANSPORT: AMBULANCE (_0 HR; CF✓ e69:, �� .:`•JY.r Y, tiv CIDENT LOCATION: %+E- �.�_ ;r� , ? RESPONSE CODE ? REQbESTED"BY ;TIME (24 HOUR CLOCK) CENE ,f,' [] S.O.»s�,., :CALL=RECEIVED: ' / , v ; '= e�'7" '. �r TIME'10-8°ice 1TIENT DESTINATION '.; "- '' .- [� P.D. , f) M SCENE t TIME.FIRE TIME -4P 10-97�i` jam,• i . z : 10 /5 r x: .. '�„' :.TIME 10 DCTOR� I.. �.�., ` � l Pt�ID/ HILFAGE•����«� . �[] PSAP „ � END22 . I °TIME ' ;10-98S , R/ VV, ;TIME'10-22 THEV . STAR k. .. `. 3 ` STANDBY x TIME .� A [n a NEAREST�: FAMILY:R. IgFER TOTAL ' .WAIT,,TIME a Q PATIENT E] DIRECTOTHERp,,,t„o + ' ' CALL BACK# AMBULANCE.:C ANY, 'T."' AMBULATORY? PATIENT TAKEN .TO,AMBULANCE• v ,•; t k"fe �1� ' ) tai .;RESPONSE4ZONE� YES NO �WALKEI) IERNEY �J01`iiER � " )+' ';s'^ PATIENT:-.CONDITION." DRIVER {�� `� 4�TECHNICIAN PARAMEDIC ` l:�*+�> Hx..` ✓K^. dr-�..-• .: , r ,.DISPATCHEfit. R CHIEF COMPLAINT C..1 DRY RUN:( YES [] N REASO FOR DRY. fn �' ''AUTHORIZATION FOR DRY, RUN (EMS aUSE'!CONLY t�M ! +1�, tx6�4; ,: • ;' PATIENT REFUSED 'SERVICES: "(SIGNATURE)X COVERAG(/�+ ' , �`' ` IND ISTRIAL 0 YE8JNO NyO.k OF PATIENTS � ���t Hk •— f • �7/7 •" :t''k/'/, ' Cif + ,�:A, � ��7..{,,.�1� 41C}.. �{ �{ rt -lv . � � E '` ' 7•"(.y �. � ... i PRIVATE INS. CO BASE 'RATE : ' .t, t R V Y, KAISER �f: ” ` t MULTIPLE PTS.".BASE RATE`_'� +t '• ' " BLUE CROSS 1{. TOTAL' "'MILES. `=DICARE'?11, — •• E.0 B ATT. j;ROUND TRIP: EDYE �'* [� N0�,vjf m,;f �•.��•'+' YES NO NIGHT: (14:00-07.00) kr� t �.. '�•fin',� ❑:. � �CCHP/PPRP Q _ EMERGENCY RUN: r. Y 'M f.• ,.MEDI-CAL CODE(Z) / '3 'OTHER: 4.,::r _.OXYGEN: PER TANK �'P:0!E. ,STICKER .:':. (] YES (� NO ,^; , _;; r NEONATAL: . (INCUBATOR) {. i` .•� � DATES BILLED: 0�- 7S, cSLgy' STANDBY: (OVER 15`MINS.)�` yr _x. , E.K.G. : (PER EPISODE) . as a'll­ x, VtIt ' N ESTIVE/RE PONSIBLE PARTY. ' I.V. : .(PER ADMIN.) x � ,WS: (PER ADMIN.) N 'o•�, RELATIONSHIP �vL E.O.A. : (IF NOT REPLACED) 'ADDRESS: " `" `� ORAL AIRWAY: (IF NOT REPLACED `CITY: STATE ZIP: C-COLLAR: (IF NOT REPLACED Q WORK PHONE: DRY RUN: (AUTHORIZED). • r ,'�" .r r<EMPLOYER: OCCUPATION: OTHER: , 'r °'ADDRESS: 'CITY,: STATE: ZIP: A '"COMMENTS: TOTAL: 77. 06' ' ` r I PATIENT. RECEIVED BY: mss! I ' + i (Signaturea..T �1�111�1TANCoil CE ULMANU NU. ZU4 0 i..., �: . l• icy VENA M M A : .z::�'..t , r� on the Treneury of the r 4 '4 O ;,; .• Nt , . COUNTY OF CONTRA COSTA Presented. By: STATE OF CALIFORNIA DATE 5-18-82 ' CADILLAC AMBULANCE SERVICE, INC. ;•;` .•., kT; .,..- . '.NAY[ IL Aa r) , (FIRST) MPORTANT 4601 NEVIN AVENUE See Instruction-ion Reverse Side I. ADORES! ' RICHMOND, CA 94805 CONTRACT # 22-079-8 AxTj CITY, SC'TAT[ .. . a E 1.1 )t f <,7( !,f �•^• �DATE7'w-1-81-"to•'.�6 K-•'30->^48 t 1..ry�+K4i' . 3 L-t , 3� *******ONE THOUSAND FOUR HUNDRED FIFTY.THREE AND'10/100** For the sum of Dollars 3z� As itemized below: PHP MEMBERS - - DATE DESCRIPTION AMOUNT` ''''' S` t Y x cnRWAR p — S CHED PAGES 1.•-y Mealcal bervices C= ` �Qda4d t, D2 fu 6 RECEIVED - : AY 2 01982 �G FBF Emergency Medical Service :c. The undersigned under the penalty of perjury states: That the above claim and the items as therein set out are true and corret (iia► no part thereof has heen heretofore paid, and that the amount.therein is justl du , and that the same is presented within one' year after the last item thereof has accrued. Signed vt:NooR No. Received, Accepted , and Expenditure AuthorizedIto n � ,�•��� '' DEPARTMENT MEAD OR CMIET 9a Tv._ .,:.. •f5 9 U111.NO INVOICE UTT DESCRIPTIONOU r • C 1 ► Yr N Y U 1 PaoV &� t�� 3& � a ,< M C TITT NEC. Ilal. , DISCOUNT �..1 &Ur. NO. INVOICE DATE DESCRIPTION IYNO ONS. ACCOUNT ENGUIISRANCE NO• P PAT WE NT AMOUNT 1 _1 :. >. - AMA l ■OYSi TA1{ OPTION ACTTVITT DISCOUNT . 1 , f1M. \: D 4=1 DAT11OESCRI TION FUND/044. ACCOUNT 911CUMORANCE NO. P/C PAYMENT AWOUNT 44 1 I 4' ..., ��. .:' • fA{ASIE AMOUNT 1 TAS{ I OPTION ACTIVITY IP" Raz 01 (ale Rn. 7/77) 7 w W�'r. �rl rr. ' , •�� , _ , 1 � - i motif 4 \ ..{ L (•fin� t �`ry�ti• S 11 n. y..tit ,, ✓.,yy� J 1 1"• b ... 1,,. ... , d>."A y�j,, 't r =t yjt I ,7 y,� + f r V„i -t.j 761 �� '' t t t I . .. � .�' ,t. �Yr 1rY�'r t �i 4 ` T � CONTRA COSTA COUNTY AMBULANCE ��" ;`� ,• PRE-HOSPITAL CARE FORM I try UNIT' I AUTHORIZATION# I CHECK OR FILL IN APPROPRIATE SPACES al^'� •nWqR (' t 1` 1. •n 1 +, =j dt, t y� ,I[�,« <•�<r rr > yS r r�.t.Ua t,• I .I �b 1+)Yr.Tjtf fT '.:" rI.J,r Y yi + ,: i '� r r•1'( , # ( ,t 4., S 1 .. 1 R�1 A ��Y,�r 1'. ,t PATIENTS NAME +❑ M 'r{ COMPANYiII �'` 1 ? !• Y w 'iir .O fy0. �• +� . 'yltyr ,Lt ) 'JiJric� yN`�t.�-•'' `�'r�i 1 .r....... +YYAGEJ�.>Z. a + �• I •� a arADDRE '• � `.CITY ' rk 'STATE j'.' ,)Z p r DOB ��1 'U,t� ❑'Sn. ❑ 6A �)* '❑ ❑ ❑}_ ❑. ; t 1 ,.`a .,'j• C K,{/3r } y- 1/"+lam r r. •Y}IC � V•T!T # �4�'fcl�Gfv51 ��,�'l�` +\� � DRIVERS LENSEPHONE NATURE QF DISPATCH ' I TYPEOFTRANSPORTAA)B_ULANCE +OTHEDI❑ r`j • " } '+ t I, .i 47�w'r.j ya.E;Yb jt+ '�'� �i .( , r,��'�7 l : �•Can•u a n 'wK-tjti:ll '�" � ���'i �`i'.tt'�t+.jl' y. 4r.INCIDENTLOCA710N , 34 j1 if wyjC RESPONSE CODE. REQUESTED BY tTIME .'(24JIOURCO ,,t N ♦ J , IY' L .' 1 TO.SC N ❑ S OE:Z • �+�.;.; LCALL„RECEIVED.• '' 1 ; • • r�' xl if. r „� Ilwlr%n �`�• f '� J v ` � ��C�CY'(C?f1 L7 �' ��es � �❑ P D ��4yI9' STIMEr10.B' '� F f 1`IPATIEN DESTINATION �s �j( W,r y FROM SCENE�' > ❑ FIRE + 'ah' TIME 10 9 , 13•I',.i1Lk�`;{S'.prt I� ra „-,> )Y, ` e.. s;>: 1ST r.�'�.+ t ❑ '�k !c• ,1 r { 1 .,t ' }t nr, PSAP` TIMEf`70 49 MILEAGE"' ILEAGE �' �9 a .❑10T R/PVT•r T.... •END;'fit� TIME 10.9P ♦ rl.:. ./a< i1A. {Y Cs R [ OR l ,TIMEa1•0.,22bOCTt •�4fi HOW CHOSEN 4j'( l'ti..i'« l 1� . �",�;,.{' TOTAL ` ❑ NEAREST j 1❑�AM(LY: ;' RANSFE IWA17txIME+ f <;r ,F� '❑'PATIENT Y ❑.DIRECT ❑ OTHER! -i �q a� CALL BACK k?'+r AMBULAN E O ANY :` _ >S. 4 rmRt,ESPFOiFNTi!SaE`Z*OqNlIENT ❑'YESBULATORYI PATKEN OAMBULAjCE ♦PT'AMtrE~•(� �-'t"K.'tx+''f . K .- ❑WALKED ❑ GUERNEw30et 7HER _s.. . i, .� tr f` t,r i♦ i '_' v ... «. it', ,-7p�+i" Iw•3�k _,/ - ATIENT CONDITION til ! a)'2�2}� '° I`sk DRIVER'" �h «.* ti 3i Ht} +�SJ1� ai.•'"�;'r t=t ECHNICIANAEDIC��w)t,d� y,D� #i?ry7 Y Hx L�� `QD r Off" 3 �JU-�'L + DISPATCHER`. > I 'r , ;:' DRY RUN`y❑YE REASON y+` CHIEF,COMPLAINT •.�C'�s ��`� r�'^ R S�NO N.�OR DRY'�RUN ` �• '!,1(,1, ; _ .� - ::�1 +',�'. ,, r .` ,_ :. �' ,y fr 1:. [AUTHO,EiIZAT)ON FO"p{DRY RUN'(EMS)USE ONLY)+'+ ����'TiFsl*'" " �•C>a.;, 'j�d,r -."hY. .^.(' ! , .. +.�.ti\ L.r:7e�a �Y Wa F'•e?eCYI.•R > S q ,p ,PATIENT REFUSED SERVICES (SIGNATURE) N •I. . - 2: 'MEDICAL COVERAGE �r Yr4�+ (;INDUSTRIAL ❑ YES1J0 NO OF PATIENTSU� C T rf p . 1 1. r Y T" Cl li .J. '.;xr L ,. 7A•-, N ♦ 5w 1�i' +�! al•M i ia':�;r 4 I.t. . ', If y tiL,�'� 11".lt'A r♦e-4 Y •f"I + ' - ! „r tTY , I ,\ ..e J r: n -r ./: ,• zl PRIVATE INS CO, v y BASE RATE Fr T2 KAISER q * " s MULTIPLE PTS BASE ..._{a,, ,�♦ •Yl, � +1 i{41 I w' -. , �.t , I 7 '\.• w •!''1'�)•„�Y! �. 1''J! -� BLUE CROSS q TOTAL MILES: Xdo — ' E.O.B.ATT. ROUND TRIP:.:,'O❑ YES ❑ NO x N orf MEDICARE A [ i�Ftt• , !� �� rD(�3YE�❑ NO NIGHT:(1900 0700+) 4 , -�a.�, 1 •.. CCHP HPM J EMERGENCY gUN 'q �`Y "' ` t 77 CODE 2 l 3 MEDT-CAL N s .� f 6h i i Y s ". Y £ 5r v� , 5 3• t ctyy S� ,•- zr OTHER .OXYGEN:,(PER TANK) ,,,�,. y; _ y SR F O.E.STICKER ❑ YES;.❑ NO r%fir NEONATAL,- (INCUBATOR)K°S!"({ [af, R- . STANDBY: (OVER 15 MIN)K i{flit y �,J�,L 1i4 , Ley+DATES BILLED: 4, r"S n ; +t » r -+--nom+' H • z i 13 { f ' >1 .:{ v✓t` EKG. (PER EPISODE) wit .`., `.Me•,.=C,D .� J'. 1ti sNEAREST RELATIVE/RESPONSIBLE PARTY ? - LV:. (PER ADMIN.) Xr�' DRUGS: (PER ADMIN) .. r l .:X , -� + JrA- ,.i t i, a� NAME: 4.,.... —RELATIONSHIP E.O.A.:(IF NOT REPLACED) 4 , ADDRESS: = ORAL AIRWAY: (IF NOT REPLACED) CITY: STATE_ZIP' C-COLLAR: (IF NOT REPLACED) T t" ar ' a.:PHONE WORK PHONE: DRY RUN: (AUTHORIZED) is s a i+f s 1 ..t a SUL..• .k:w..1.�.I1)4,[,t. `" +k9w..�'YY a s 1' 3i EMPLOYER ' OCCUPATION ' OTHER 7 1' y ti. " CITY ESS STATE a ZIP }l Yi •.•--. r >r� f It ! -'{ rt h.� M1I=;+1+ "ta ,1C�,.. _ •�_3 tr nt f' � +[^^` COMMENTS. I tTOTAL l- - - w ,.r+.. ••• l`P• t+t ' '._. t'.1.♦ • _•'� Il •�+F' 1..:.Ij l„ i, r,,p 'v1h 4,J.”) PATIENT PATIENT,RECEIVED BY X rk ..,,.� Provider rrtadn Aite'and Pink cope :'!Retarf le?lou�eop,Y td F10uhRn bu?±ns ! (SIGNATURE) pCE COP DEMAND N0. 207 :6� _ J VENOOA N0 • Rh VKTAN _ no Me 1'rrasnry of the COUNTY OI' CONI RA COSTA r• Presented By: STATE or CALIFORNIA DATE 6-18-82 MAY[ (lA[rl IrIR. rl I IMPORT-ANT 46nl NFVTN AVPNIjF Set Inxtructinns on Reverse Side r ADDRESS RICHMOND, CA Wnr, ' CONTRACT # 22-079-8 . errr, STATE :1.t00[ DATE: 7-1-81 to 6-30-82 • 1 1 1 1 L , 1 1 I I(`I • 20 For the sum of *****ONF THOIISANDrSFVFN HIINORFO TW NTY FIVE R 2511nn**** Dollars $^ �-r- As itemized belor �NUU�ECUMLE -_ --`-- ----- DATE DESCRIPTION AMOUNT RECEIVED • -- -- -- - - ---- --- ------- —= Jull 21.1 SEE ATTACHED —Emernency- ical Ser ices PAGES Alun' ��z n ' �9 3 ccs u1�t` (A& ORWARDEO-.. _ a'Setil �rr;rMedic . �• _ � a oil _ t rz IAC AMSU Thr nndersivned under the pervdtc of perjury states: That the abovq claim and the items as therein set out are true and corret that'nn parr thereof itis twen her^_.totore paid, and that the amount therein is justly dye. and that th same is presented within one year after the last item thtireof has accrued. (.. Simied VENDOR R0. Received, Gccepled , and Expenditure Authorized i_ - r.,•.- - � Y'. DEPPRTYENT M[AD-- O—fr-CMIff�DEPUTr ,• - mum.NO r 6iTtiT1 1 lua3r>< '7ctoYTi1 Aiu1 Yo. c , rrE—TriW0UN7 t.til nil t �i4�leS I cyr,� p t 0'iT llbiiT— n e rlTr fr[e refs Dneourr 4.: ; 1 1 � 1 . fUr. as IYr01C[ Oli[ FFM Of 4 C a IP 7 1 a a FUND ORa. Rt COURT [NOYY/RAYcI N0. P/C SAI YE NI AUDY%r 1 I _ f 1 1 � �4A.i f��1 fNx pF7 qY ACTIVIST DQt:DYNT f , 4 ifUr,aO IYrO1C T O(V Ci11�IJNW /YYO OR/. ACCOUNT ENCU%/RARCE r0. PIC 1 /RY[YT •YOYNi —.A— r ARAOLI Am IUAI TASK OPTIOR ACINRY /PEC SIJ! 01 Cil y-)5 • (D18 Rfr 7/77) ' r CONTRA COSTA COUNTY AMBULANCE +tea ir KIE-HOSPITAL CARE FORM I UNIT AUTHORIZATION# 209 1 7sr CHECK OR RLL N APPROPRIATE SPACES DATE: PATIENTSNAME��L n 1/ /f I� �`� �'M OF COMPANY# ii ADDRESS U S" .7 7k'. ✓ LL A AGE ' �- i CITY :r / i�: /� `.� STATES ZO / IP ~u�{'4 DOB 3 -/� - Ip SA O M. O T W�n O F O Sn DRIVER'S LICENSE# PHONE^ . ' rX ly7 NATURE OF DISPATCH' TYPE OF TRANSPORT: AMBULANC9 OTHER t ? INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME-(24 HOUR CLOCK) ' s TO SCENE= Z- O S.O. CALL RECEIVEDi/ �i-t/I d i✓n lza 1-- O P.D. TIME 10-8 I O )' PATIENT DESTINATION: T— FROM SCENE- O FIRE TIME 10 97• . O PSAP TIME 10.49 . �,:� :•l �..�.r}'•,: I C N/L MILEAGE: O OTHER/PVT TIME 10-7 ,, t ' END TIME 10.98 �!;•, DOCTOR PM�/ER STARTS' /-y9• y ; ��'L�' 12 rli� TIME 10-22 Y/ HOW CHOSEN: TOTAL STANOBYTIME NEAREST O FAMILY -0-TRANSFER ( WAIT TIME w, y ' O PATIENT O DIRECT O OTHER ` I CALL BACK#: AMBULANC�CQMPANY: %�qr F.AULATORY? PAT!FNT TAKEN TO AMBULANCE: RESPONSE 20NFQ NO i O WALKED O GUERNEY.)-OTHER `PATIENT CONDITION: DRIVER i IL, } TECHNICIAN 1 �n� > PARAMEDIC ,, t Hx: DISPATCHER: CHIEF COMPLAINT: / - -.DRY RUN: O YES O NO REASON FOR DRY RUN .7 y •' ( ���� AUTHORIZATION FOR DRY RUN(EMS USE ONLY) r PATIENT REFUSED SERVICES:(SIGNATURE)X MEDICAL COVERAGE: INDUSTRIAL O YES O NO NO.OF PATIENTS: ✓ '�' �� _ '`-.w _ ml S.S. PRIVATE INS.CO.: BASE RATE: S/F•3s1'�' KAISER N: MULTIPLE PTS.BASE RATE BLUE CROSS C TOTAL MILES: 171 M X , s : MEDICARE 0: E.O.B.ATT. ROUND TRIP: OYES ONO } O YES ONO NIGHT: 19:00-07:00 . .r'..• CCHP/PPRP N: EMERGENCY RUN: f ". •R 70 '' MEDI-CAL N: CODE 2 13 OTHER: OXYGEN: (PER TANK) P.O.E.STICKER O YES ONO NEONATAL: (INCUBATOR) € 's DATES BILLED: 3-0 12,y L-/ R L STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) t' NEAREST RELATIVEIRESPONSIBLE PARTY: I.V.: (PER ADMIN.) X f. DRUGS: (PER ADMIN.) X NAME:' << ' C. ` L RELATIONSHIP: E.O.A.:(IF NOT REPLACED) y L w . ADDRESS: L ORAL AIRWAY: IF NOT REPLACED) ) CITY: / ' t1 STATE ZIP: _ C-COLLAR: (IF NOT REPLACED) PHONE: - ! 7 WORK PHONE: DRY RUN: (AUTHORIZED) 'S N EMPLOYER: OCCUPATION: OTHER: ADDRESS: d } CITY: STATE* ZIP— COMMENTS: IP COMMENTS: 10 is TOTAL: :PATIENT RECEIVED BY:X PfovidOP tvtein white and A'n' copy Returl, fellow eon to M:wA Filling (SIGNATURE) Z �'�1111 0, IVI vu•Irmu 11U. 209 VENDOR NO AL rin Ole 7rcnsuly of file COUNT Y O17 CON'IIIA COSI'A Presented By: STATE OF CALIFORNIA DATE 6-18-82 ; �anrllnr AMBULANCE SERVICE, INC. NAMEIUNT) (r INIT) 1 1>fI'UR7-ANT 4601 NEVIN AVENUE See Insifuctinns on Reverse Side AODR[I7 ' RICHMOND. CA 94805 CONTRACT N 22-079-8 r. . CITY, STATE zu cont DATE: 7-1-81 t0 6-30-82 r•Q V 1-S.3 S For the sum of ***ONE THOUSAND NINE HUNDRED FOUR AND 40/100********** Dollors jF17,9e'4-74151' As itemized below: UNCOLLECTIBLES _ DATE DESCRIPTION AMOUNT bfE—AT _R ED _ ECQ\IED G/<< CPO ' PAGES —JI;VI21 j"EZ qMe -- __--•— _--. CL^�[SeJ I'1edi=alSetvice ''Ct•-- I' /(o, it� —WV t ` •��W'Y[/�-�Y .'` r"�� _�f{�"/�, cnRWARDEn v4i1-- k,od GGs,- - - - - 19R,2 a •;ervi;c- I•he undersigned under tl:e penalty of perjure• states . I'l:at the above claim and the items as therein set ovt are true and correct; That no part thereof has been heretofore paid, and that the amount therein in justly.due.! and that the sall)e is presented within one teat after the last item tlicrenf has accrued. Sign k] i• {: Receic-d Acre:,ted and Gave dituro nutholited i 1 1 � � DErAOTY1MT-M1A0 CR LNIEEIDEcyT7 5UW. NO 'IIm'ill MA .Mr 6iii ALr Y�AF _ .f 9AnC[•Mii. L • YlltWT ANOUkT a D► i N • - -c1TIn rrtc rl. 1NeouNT IVM. NO. INVDItt DATE a I ICn Ir TION FUND ONE. AC CUUMT tNCUNrAANCf No ►/c I FAVNf NT AMOUNT I � ' J.� rANAIt Ae0UM1 TNN Or-=V+MAttltlTi OIICOYMT NUY NO. -IRVOIC e.T}2 '�W-....:..�`.-J•_ O:Ir•r I�^T 1011 FUND CAN. A.Cv.NT axtuNt1lAMCf `10 NL , rATYI Mi AYOYM; TANAI\[ AYDYMf � -t.-t Crf ICN At (VITT VI♦ Ilii 01ICOYNT tD16 R.r 7/77) .. �f. I-.--�– .._�_.. l —.-- I •�O.�t- CONTRA COSTA COUNTY AMBULANCE I i PRE-HOSPITAL CARE FORM 1 UNIT = AUTHORIZATIONN 'a-•a -� CNECKOR FELL INAPPROPR/ATESPACES DATE: 12 �< PATIENTS NAME t: l n U 11'Q A1\.( ky S 0 F COMPANY ADDRESS �� .� � 7i I� AGE CITY STATE S—ZIP DOB l_,J/ O Sn O M O T; O W 0 Th OF. 0 S_; s r ' - DRIVER'S LICENSE M PHONE NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE 0 OTHER O Y INCIDENT LOCATION: RESPONSE CODE: REOUESTED BY: TIME—(24 HOUR CLOCK) TO SCENE- ❑ S.O. CALL RECEIVED _ F Z)s 7, 0 P.D. TIME 10.8 ` PATIENT DESTINATION: FROM SCENE- 0 FRETIME 1097 2 ,i,� �_•'.': O PSAP TIME 10-49 �� : 7� '+' () �'ln MILEAGE: ®�TI�ER/PVT TIME 107 END TIME 10-98 r r� DOCTOR �01d Cti PM ER START �H TIME 10 22 HOW CHOSEN: TOTAL STANDBY TIME .0 NEAREST 0 FA(dILY , y* TRANSFER WAIT TIME O PATIENT 0 DIRECT 0 OTHER CALL BACK N: AMBULANCE COMPANY: ,+ Ae '• a PT.AMBULATORY? PATIENT TAKEN TO AMBULANCE:_ RESPONSE ZONE i,-s: 0 YES ONO ❑ WALKED O`GUERNEY•13-OTHER PATIENTCONDITION: DRIVER EMT-IA TECHNICIAN IAIAL_L - PARAMEDIC tl Hx: DISPATCHER: �, ( . ,...�_ 'y. CHIEL F COMPLAINT: rYta`•A I I I C� ( DRY RUN: 0 YES C�NO REASON FOR DRY RUN w ; AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES:(SIGNATURE) X ;,: + • + a�-6u T MEDICAL COVERAG INDUSTRIAL AYES 0 NO NO.OF PATIENTS: PRIVATE INS. CO.:"- ,i cA..•1I,` i :; L,, .. .'. u r r' r t%.f BASE RATE: �1�35- :~j • KAISER N: MULTIPLE PTS.BASE RATE 'y; BLUE CROSS N: TOTAL MILES: /C M X ,2..1[�: �lhnt2•:.;.; MEDICARE N: E.O.B.ATT. ROUND TRIP: 0 YES 0 NO j'•'" 0 YES 0 NO NIGHT:(19:00-07:00) - - CCHP/PPRP N: EMERGENCY RUN: MEDT-CAL N: CODE 2/3 OTHER: OXYGEN: (PER TANK) P.O.E. STICKER OYES ONO NEONATAL: (INCUBATOR) DATES BILLED: )!+ / ;_fes y �� �- f STANDBY: (OVER 15 MIN.) g` E.K.G.: (PER EPISODE) + � i NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X •:,';��=`{ DRUGS: (PER ADMIN.) - X ,G NAME: RELATIONSHIP: — E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: STATE ZIP:__ C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) t EMPLOYER: ) I�;.i. ;.G/+•1 OCCUPATION: ° ( .JOC'FIE'Rr :c:yl } !V t ADDRESS: CITY: FL1 t-� STATE: n ZIP � y COMMENTS:-_ TOTAL: 9J. •>5- ;� t: 10 PATIENT RECEIVED BY' XI -• ` � ''- 't` --... -:� ' h'^:;rwr main Ya1�:r .�: i(r: r•.pe FICL+•n Yn;f,a• •n�: v ,,, .,.{:.; ,(.. (SIGNATURE( i fV1I t�� `f CE C(SY DEMAND NO. 210 ��.� . • I,1•,�IANu VENDOR—NO- A on the Trceoury of the #`aao 60003 a COUNTY OF CON FRA COS'hA Presented BY: STATE OF CALIFORNIA DATE 6-18-82 1` CADILLA_C AMBULANCE SERVICE, INC. MIME Il Il T1 a2 4601 NEVIN AANUE 1+troarn Sec lnstrucu(ms nRen Reverse Side ADORE!) RICHMOND, CA 94805 CONTRACT # 22-079-8 ; CITT, ITATi zip coo[ DATE: 7-1-81 to 6-30-82 1 1 1 1 1 1 1� `1$Lt 9 . For the sum of ***ONE THOUSAND NOE HUNDRED THIRTY FOUR AND 551100***'* Dollars As itemized below: UNCOLLECTIBLES DATE DESCRIPTION AMOUNT SEE_ ATTACHED — kFCEIy � - Jul� 1 PAGES' ' r 1 ergrrcY Agedica c ' 'i• +F�u l.��lu. it 1. ..�I .�t.' d�ll j�l'/} L ��C�>1;4�1.T i'D .^—.---------- — �• ,. ,i U ?lb )qp -o 140 • j. crgrn,p%edicat ,rvices 1 _ _ 9 The and^tsit:ned under rhe penalty of perjury states That the above_cla-mi and th•i itt;ms as therein set out a0ft, correct; that no.part t.het-of has b:e:1 heretofore paid. and.that the amount therein is jusgy1ducy, and that the same is presented "� Vne ` %-ear after the la t. item thereof has accrtiod. '�( / n ✓' t vtNonQ P421- Received, Accepted , end Expenditure Authonrad C 1 CF'hPTVLMi litl0nRCNi%f CSIUTT Aug.All), 117 ICIr'LAfP" _ TTS2iTiTiER� �- -" lu`»rie•.): ` : F -IW.uu VAkCT-eo o.0[_r TYtw /You l _� `� c 4ITY1909; 13couN r . .. � �r i — Ixs rite. 1 tUY. ■0. INv01Cl - �LDA. L�'• O.lU-.C•N•IPyTIOANte• •. Ai UNIc76x A��Ccuhi UY2NANC1 N0. P/C PAYMENT AMOUNT 1bD'Ja/ CP110N 016"UMT 1 r r tUY NO. INTOIC IY - - yrOx f:no 440 PUW0, 0. �I:GC':7T INCYYetANt1 No P/C , NTMI YT 1 TUAOlC 1YOdN! :AAt iIT K'� C777-17 T tPic ria! DI)COuIrT (PIS NtT. /77) • I ,�� 174 n ., C •. . w1•a•a 1 �L t1{ 4 1'r 't.Mi ri'{•h ! . a iYr'Y , � `I, - • d A i •. _ L f: .'i r 1 If :_�,: if uTr ly r a t ,, Tr pry^ )t tlri -' CONTRA COSTA COUNTY " 'R•' AMBULANCE 'Z7. 14al. £)!;; PRE-HOSPITAL CARE FORM 1 ,�' ,� „ UNIT AUTHORIZATIONN V��`(•!� lSr h.'l�rf`£1 •'. .1 .• E.- r 1 1 •j��:'iTit�il/'��` rk •Y a ail CHECK OR FILL IN A/P qpRorp pACE8 " 1 . Z +k • " DATE 1 F. .ntt� �1M,`v r � �1 T" , :�ri�s i� h �°•�L , �' PATIENTS NAME "�,r../�J� + C,�+7 L 4{ .5� '1� j( .. �E7 •G. "'C� i�r I J�jn r ❑dM~ It 1". COMPANY . s•,rr ,, I,eel, : - '•, JP !F`.i Y' �� '� ,ai'ADDRES�$ J .11r + r AGE ' • URE❑ �,. hep+01 -$ 0 _sa❑'(::S'Tti +' 1 ' aCITY / T TATE' �lap,tD08( �"t TT S .•aS:'2' �, wtJhF.Y rr) !1Xs, . . ,rJ t MI•A. ' , rjy lF.l o � 1 DRIVER'S LICENSE N , '- ' r 'PHONE T'�Z 4� -y NATOF DISPATCH' ,C . •. hr•..�. .1, : . r.., i TYPE OF TRANSPORT.,AtyIBUTANCE❑ OTHER❑ "''� + '` "" ' '°" 1 /". o t<�'n "-.�.;f�i.*' '- ! ' '+ 'w�.i.�, - v ''rti' 'T 1 e 'Q,'�J+r—+57a'f1 a'r's S7,w� `.I, p s �J� )kMt• a i .W - I 1 " +,�' .r I., 1 1 ,.J.`!fi4 ., 1 T ' :1 a''f• '1 .i , ' r , INCID T LOCATION '"'tom I: .v,' {+ �£' RESPONSE CODE REQUESTED BY ! :TIME,. (24 HOUR L K), +T •^•• f H )*1 y yt. r `t $z i!tg'r �=' r❑ SO �r .:CALL RE,EIVEDf`+IX7i:� TO SCENE TS FROM SCENE r CYENE* v IME 10 7PATIENT DESTINATIO� t ❑ FIRE -TIMEs �4 _ _ ,g/(aIUr4:a �a'�"t MILEAGE 'Gr OTHER/PVT;:fTIME 10- r _. . 6CM 1'AM .syy�'. �� tit _.s`C it's{. ..1'�L'� �, i ai (`i7�. •!M { ti .^ r,J Ch+, '�TIME';10.98 - a.., �ti . ^t j h „ ENo „DOCTOR ? PMD/EF( STAR ^°i TIME 10 22 i „..y S'� ' 'A.TI I:.. t -, ,{d 1', r Y,..' T 2'♦ i.{ iJ Y 4 OW CHQSEN yQ Z + TOTAL — STANDBY TIME T + ..r " WAIT�IME sttie, ty (:t y❑.NEARESTS� D,FAMI Y TRANSFER 7 K ry 1 ❑..PATIENT D D(REC7 O OTHER _ CALL BACK N i,t, `AMBULANCE COM - +. ..- ,. 1 » - i tL.S..r 'i/ LIt't �� s•'I All 7, PY'AMBULATORY? PATIENT TAKE TO AMBULANCES { "+ET';a„ y t �; RESPONSE ZON r ❑'WALKED GUERNEY Q,OTHER �' ;s 1 k, x, 7.-.T ty�q ►t�duay > D:YEQ r i` ' y: t t .}la C ,:h'; 'S "7A:' / .r ` ••SJsp,J�1 !i ' '1 P TIE CONDITION cr y A rK y�g if„ J' DRIVE�i�/' !, y� r'ITJA 7 P N 't fir ,a, z ,,, • ' ( r ':TEC 1CIAN /��r�"� PARAMEDIC the' .J- a. r i °Hx77 �'ri ��'K! DJSPP4TCHER r7 t CH EF COMPLAINT { I� ` Q °t DRY qUN .❑ YES NO ,REASON FOR DRY RUN rR�y RW./, r } t •`' iAUTHORIZATION FOR.DRY.RUN(EMS" ON h �•-„ PATIENT,REFUSED SERVICES (SIGNATURE) X M1 y� MEDICA} C10yFERAGE INDUSTRIA ❑ YES NO NO}OF PATIENTS: 5 �7 77 'j Y K�f ' 4 S S.N 'M 't,.. r':1 P T +. ♦ 1'ix L ` t''C 1 f .,"'•'n rJ r ' 1 7t , $r iFr + ' }R, ' ' PRIVATE IJS COif „ BASE RATE: to + f. KAISERA a/.��� A �' tMULTIPLE PTS.BASE RATE `BLUE CROSS N r TOTAL MILES:' SM Xr f ' r{y< �rt MEDICARE N 1 E O.B.•ATT+' ROUND,TRIP: ❑ YES ❑ NO..,,;., i �r+' " r ”❑ YES D NO NIGHT:(19:00-'07:130) kYc CHP/PPRP A EMERGENCY RUN: , J a d .MEDI-CAL N 1 CODE 2/'3 `'rx.�;l OTHER" - - ,OXYGEN:.(PER TANK) j)••IF"rj;' , ,` A 1 iff 1_. c)(W,� 1 ►sJ U' v-%.�YF. i.' 1 21,11,"!-,y�J P.0 E.STICKER D YES _D NO NEONATAL:'(INCUBATOR) a .All `+DATES BILLED: STANDBY: (OVER 15 MIN) + to r� f '' '7 `t�¢kE,yAe loo E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY I.V.:"(PER ADMIN.) " X' kt•, t y DRUGS: (PER ADMIN.) X, t tI __NAME.1% r^��' 3i' �/Cr J RELATIONSHIP E.O.A.-(IF NOT REPLACED) 1 v� ; ADDRESS: ORAL AIRWAY: (IF NOT REPLACED),:.;,.;! `� "�4 s's{a CITY: STATE_ZIP- C-COLLAR: (IF NOT REPLACED) t . PHONE: WORK PHONE DRY RUN (AUTHORIZED) 4; EMPLOYER: OCCUPATION OTHER ADDRESS: + '•r`e + CITY. . STATE' ZIP•• t �Vc I J+ -COMMENTS:. ds < TOTAL--, r ) PATIENT RECEIVED BY-x= L1.1�1i` •• Provider retain mld Pink ropy Retw.l'leIZau oo to me when billing (SIGNATU E)1. " •v .. PY f-. •�°' - • �I.A1,1N"1)�� �il� DEMAND N0. 211 � VEN D_7R N __..__..22J� 6 0 0 01 nn the Treasury of the COUN•FY OF CONI RA COS I'A Presented By: STATE 01: CALIFORNIA DATE 6-18-82 CA01LLAC AMBULANCE SERVICE. INC. NAYL (LAST) (FIRST) � IMI�ORTANT 4601 NEVIN AVENUE See Instructions on Reverse Side RICHMOND, CA 94805 CONTRACT # 22-079-8 cIT., STATE rn coDL DATE: 7-1-81 t0 6-310,-82 , 1 I 1 1 i 1 2 .140 For the sum of ****Q� THOUSAND EIGHT HUNDRED TWENTY AN�85/100******** Dollars As itemized below: UNCOLLL-CTIBLES DATE DESCRlrltON AMOUNT RECEIVED .SE ATTACHED — - � — Emernenry Mediral SCiviCSS PAGES � l r h,4-LaLtLG j2!L- /i>y �__l 7 C GLI Ll jyi 4—Tt!L l C.n^r0enw N,cdical Servkca c' • a 0 'Fp r The undcrsipned under clic per,:ilty of f!crjun states: That the aLm•e Clair( and the jt(:ms as therein set out are true orrec HIM no part thorr.of has ticen h1•r(•tofnne paid. an-1 that the amount therein is icsily.lin;•, and that the. afne is presented wit hitrr'�tte Trc.ar after the last, item thrreof hits ahcrned. Si VEN eived iiDOn +1 n. Recrr •: -- cpted , end Expenditure AalhcTecd 'LD _ f'i -RTY[RT MiAD 4R CMI[! DEPUTY ON �,y / CJI 1iII NO-r t ST�ST:TT'oti '" 111tKS7`D;S. Amo,: SvUmbRAICT N• .]c r Tr N Y u T/� �•.^h�(.�•� ' x`712-- `-� `"x"�"""j''"•`"'�""`'-•�-J'` Yii�Ti. b��F'- Tiii O-L c VITT SPEC PLOT. DISCOUNT sum. N0. INVOICE eat[ w.,,,..._.�.._.... OxiiLNI►TION ��- /:.10T0�S. AC COURT LNCUMSRAict N0. F/C , PAT WENT AMOUNT 1 I TAxANtF AY01! T T'ii OrT10N ACTIV!TT OUCOUNT L._ l _�. _ _ 1 IUM N0. IMTOIOTTIf •''-"- -..........,._._.-�C[/CR �ION� — L#J" A PLCbUNT LNCVYLNI,NC[ 40 F/[ !NY[�7 }YQUNT [ 1 yl1 • AM.- 41 IC I�FDISCOUNT I1 -I (Ulf RFV. 7/711. * + Y CONTRA COSTA COUNTY AMBULANCE ORE-HOSPITAL CARE FORM 1 UNIT AUTHORIZATION M .r ��7 �`"� C•w CHECK OR FILL IN APPROPKIATF SPACES DATE: I' :i PATIENTS NAME I��� ...�.,��:e. ,_ ,—� I i/)/ 1`l t�_ ❑ M �F COMPANY# ;Y ADDRESS AGE 1 ,iO CITY_ STATE ZIP DOB I ❑ Sn El B l 13Th ❑ F 0 S V` DRIVER'S LICENSE# PHONE NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE❑ OTHER❑ %.•: • �,} INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY:. TIME— (24 HOUR CLOCK) >• •`K;i TO SCENE- ❑ S.O. CALL RECEIVED ,•-�, F�i ❑ P.D. TIME 10-8. PATIENT DESTINATION: FRAM SCENE ❑ FIRE TIME 10-97 _ ' / ) , ❑ PSAP _ TIME 10-49 t � �L y�_�` : MILER C�p7HE"V� TIME 10 7 :`,2�� _•"{ yr• �- END S TIME 10-98* .. :• Y DOCTOR /Y)MS P /ER START � �� � TIME 10-22 HOW CHOSEN: � TOTAL STANDBY TIME . ❑ NEAREST 11 FAMILY1 TRANSFER WAIT TIME _yet F ` 13 PATIENT ❑ DIAGCT ❑ OTHER POT CALL BACK#: AMBULANQE C NY: ;``f"[h'+Z< PT.AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE v / .•.: u! NO ❑ WALKED �+ GUERN15Y ❑ OTHER " r �:. ❑ YES PATIENT CONDITION: DRIVER .fyL EMT-tA •-� 1' TECHNICIAN 7PARAMEDIC •, Hx: \J)C! t1f.�k." (J S b 11)�f�5f- -DISPATCHER, G t�. .• r' (. i t }- #`' CHIEF COMPLAINT: DRY RUN: O YES Q NO REASON FOR DRY RUN "''F't•�' ,! LEI •AUTHORIZATION FOR DRY RUN(EMS USE ONLY) " t PATIENT REFUSED SERVICES: (SIGNATURE)X MEDICAL COVERAGE: INDUSTRIAL 13 YES NO NO.OF PATIENTS: S.S. # y PRIVATE INS.CO.:_ BASE RATE: KAISER#: !' <y��� MULTIPLE PTS. BASE RATE BLUE CROSS#: TOTAL MILES: ZDiF -- X1k AA .:­, Ii MEDICARE#: E.O.B.ATT. ROUND TRIP` ❑ YES NO ❑ YES {I NO NIGHT: (19:00-07:00) CCHP/PPRP C EMERGENCY RUN: MEDI-CAL#: �'7 CODE 2/3 • OTHER:_ _ OOGEN: (PER TANK) P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: -1 = ✓ > ,: .�— ��7 (n '! f STANDBY: (OVER 15 MIN.) .2,AgUL E.K.G.: (PER EPISODE) ai ihi NEAREST RELATIVE'RESPONSIBLE PARTY: LV.: (PER ADMIN.) X ]• r t DRUGS: (PER ADMIN.) X . >iY . NAME:_- _ RELATIONSHIP: E.O.A.: (IF NOT REPLACED) 2 �? ADDRESS: — -- ORAL AIRWAY: (IF NOT REPLACED) ! b, 'P• '.Y: CITY: — _ STATE ZIP:_ C-COLLAR: (IF NOT REPLACED) (• ii jp+: PHONE: _ WORK PHONE:—_ DRY RUN: (AUTHORIZED) 1 EMPLOYER: OCCUPATION: OTHER: ADDRESS: k 1 CITY: STATE:.—_ZIP: t 'F1l CO�IMENTS:� --S_i._I ' I' S_`-•"—iS L t _-. '!'r„ i L C TOTAL:__ I-LI,-15 _'(.�-:1�_.1'--1�._....�}.tJ .�s�•_'.—__��+..c:��=_--?-1G1{__ +' � 112• PATIENT RECEIVED BY' X— i t'r+t•: .r r' rr a: Lro•„ •' c�. , %ar: I'n:. (SIGNATURE) ., . . .. EMS-I ;:�- '• G'C�CQJD�U�f�QC� 2 U 9 4 91 TRIP. 4 : TO! Cadillnc Ambulance Servicex ' F Kaiser Permanente Medical Center, R •i O M � + i ��-,. .. • .. . .._ .::�"_" .;T.:+fir,T� SUBJECT DATE 02 /17 /82 s MESSAGE tx•�PF Please delete the following from our invoice. Our records indicate that ¢he is not a�Caiaer Health Plan member SEPTNFLValerir (Feen,Valerie)— RECEIVED D/S ' 02-16-82 FEB 15 1982 T/F KFHR - KFHO CADILLAC A.16ULANCE Thank you. c SIGNED, 3{ REPLY 4 1• K� i' SIGNED DATE .• R*difprmr 4S 472 SEND PARTS I AND J WITH CARBON INTACT ro..,+P IN urn, 4 - PART 7 WILL BE RETURNED WITH REPLY, L 113 • Uli!�1.1NU eiC� TE JJPY L D• VERS EDO on [fie Treasury n( the COUNTF 01' CONTRA COSTA '•Presented By: STATE OF CALIFORNIA DATE 6-18-82 CADILLAC AMBULANCE SERVICE, INC. NAME IIASTI (FIRST) IMI'ORT,WT ' 4601 NEVIN AVENUE See Instructions on, Reverse Side A DDRE l7 RICHMOND, CA 94805 utY, STATE E1. eooE CONTRACT .# 22-079-8 DATE: 7-1-81 to 6-30-82 111414 . 00 ***OJE THOUSAND FIVE HUNDRED SIX AND 30/100************* For the sum o1 Dollars $ �'�� As itemized below t UNCOLLECTIBLES DATE DESCRIPTION AMOUNT ---- --- -- --- ---- - - - - :_.._. - RECEIVEQ_. ...— ---9 -- -- -- TACHED _ 5w^�y 1:ed'ICyLS•rviccs I Jr .gA'eli ' CAS• �1�tc1 5 ��_�2to-���—✓�'�2�1� '�lU�d27�o2�i`a-1��� __ �.: ^ JUiv 2 5 , , The uadersicned under :he peu:ilty or p^rjury states: That the above claim and the itoms as therein set out are true and correct, that no p'+rt th;�reof has I-,!:.n herrtotclrc paid• and that the amount therein is jusil rh;c, and that the.-arae is presented within one year after the. last item thereof „as accrued. - signod VENDOR NO Received, ^Ccepte7 , end Expenditure Authorired/j—'!_._-._— - L;!.IATNTNT NEAO OA CHIEF CEvUTT 1vir-LlS' 1 I E::T1 - _ -�_• "GX1 iTT1TiA— 1 Ei 14 `L.cUU 7hTu`viltl'N'iY +u F,t PAYMENT Nov - , (Try/r/ jjqq QTS�LjI ili SvR 1' t+ 1 c rITT Ei[c ]us. o,S CouN , , 1 SUM. 100. INVOICE DATE +—�-w OEECAI►TIO• lUNO/ORI. At COUNT INC7MERANC► 110. ►/C PAVMENT AMOUNT + I _ 1 �AA NI U AMOUNT I1 tAtN O►TWK ACTT PITT DIt COUKT MIT] 1 'cT-1f D[tCRIVT DK ►URS.C.aE QAC COURT [NC UM ERA KC[ NO -1C t PAYMENT 11Y1OUlKb�T TAX yEI[ A YJUNT YAVR ►TIOK ACTIVITY VlC P-61 DIECOuNT 1 • 1 (OIS Rev. 7/77) 1--- — 1--.— Jl L4 •, • ,. ! CONTRA COSTA COUNTY AMBULANCE FJ s .r it • PRE-HOSPITAL CARE FORM I UNITr /p AUTHORIZATION Nye(�C� al CHECK OR FILL IN APPROPRIATE SPACES DATE:" ' Jv n 1,1 .8 f PATIENTS I. NFA / ' � �1 ADDRE ) y) � 14:d j" f 71 t AGE — CITY 'I / `I ('� (!`� _ �• .r + ;. STATE' ZIP ' Y DOB Sn ❑ M ❑T ❑W ❑Th ❑ F ❑ S DRIVER'S LICENSE N PHONE fIj 1 " i_ l•tL NATURE OF DISPATCH m�r(,CfJn( �iS TYPE OF TRANSPORT: AMBULANCE R OTHER❑ w• ."'I ' .Y •tr•�•� i S INCIDENT LOCATION: RESPONSE CODE:` REOUESTED BY: TIME– (24 HOUR C}OCK) TO SCENE- ❑ S.O. CALL RECEIVED I 0 ( ` /•• ( , ,: i.41 1 , �!' -1 I �i� 10 P.D. TIME 10.8 b �. PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10.97r Y' I ?'�`': ❑ PSAP TIME 10-49 ' �,�11 ���1''�l 1,.L(t�lif � 1� /7• MILEAGE: OTHER/PVT TIME 10.7 _L�► :�:.``. :r END ( TIME 10-98 DOCTOR 1' ` )} PMDLER) START _" TIME 10-22 u + (t � CHOSEN: TOTAL •� ' W. STANDBY TIME i ` ❑ NEAREST A FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT d DIRECT ❑ OTHER j "> CALL BACK N; AMBUL(I�N COMPANY: . PT.AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE' +:: - ?. :c ❑ YES ❑ W ❑ WALKED ❑ GUERNEY•E3 OTHER "'OY 61:rPAT IENT CONDITION: DRIVER I .J '(• 'EMT-1A ' TECHNICIAN r �I PARAMEDIC I !1 Hx: r I i DISPATCHER: (A �l Y • (CHIEF COMPLAINT: 1( J ; ( ' ` '( �@RY RUN: 13 YES q NO REASON FOR DRY RUN l,( ( I I1} AUTHORIZATION FOR DRY RUN(EMS VSE ONLY)' PATIENT REFUSED SERVICES:(SIGNATURE) MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO. OF PATIENTS: S.S., PRIVATE INS.CO.: BASE RATE: 1 i J L KAISER N: MULTIPLE PTS.LASE BLUE CROSS a: TOTAL MILES: d?/( !'S X ' ' k '. MEDICARE N: E.O.B.ATT. ROUND TRIP: 11 YES ❑ NO ,,::I •f ; ❑ YES ❑ NO NIGHT: (19:00-07:00) _ =s'•'..'^`. 4 CCHP/PPRP a: EMERGENCY RUN: r�a MEDI-CAL N: CODE 2/3 OTHER: OXYGEN: PER TANK) ) P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: — -'' /'?' ", y '/y •{' : STANDBY: (OVER 15 MIN.) F E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.)_ X NAME: I I 1 r RELATIONSHIP: ( JL E.O.A.: (IF NOT REPLACED) 1' ADDRESS: –4— s '� �I ` d;I '' ORAL AIRWAY: (IF NOT REPLACED) j.. CITY: ' STATE ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: _ —';— WORK PHONE: DRY RUN: (AUTHORIZED) r; EMPLOYER; OCCUPATION: OTHER: ADDRESS: CITY: STATE' ZIP: 4 COMMENTS: — TOTAL: i!> y —__ PATIENT RECEIVED BY: X—,- SIGNAT RE 1'n�;:idnr rct.tiq Dni!r .aid( ,••p'o FeL:•r•n co7':,v r,. :•• .:h:•i 'i' l f ) ERS-1 / .. . t. • # CONTRA COSTA COUNTY AMBULANCE r ; PRE-HOSPITAL CARE FORM 1 UNIT AUTHORIZATION# I v I D 1 CHECK OR FILL IN APPROPPIATE SPACES DATE:`�(.7�/(ti PATIENTS NAME I It r! (i i;' (i'(.•� l�l I( /r '(r / ,M ❑ F COMPANY +I 1 t ADDRESS f " J I ) ) AGE: CITY ' STATE ZIP''I I CLL DOBE ' {k Sn ,n M ❑T ❑W ❑.Th ❑ F. ❑ =r' DRIVER'S LICENSE# PHONE(4'11) S 3) 41 NATURE OF DISPATCHPJ TYPE OF TRANSPORT: AMBULANCE) OTHER❑ INCIDENT LOCATION: RESPONSE CODE: REOUESTED BY: TIME— (24 HOUR C OCK) ;:` .y f.flk ( TO SCENE- ❑ S.O. CALL RECEIVED. %O , /-.4; url /�(! � T� ' ❑ P.D. TIME 108 PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10.97 I Y�. a ' n , �• I j _L[O - _ .. MILEAGE: 1 OTHER/PVT TIME 10-7 END ! '• TIME 10.98 �_ .:•. ",'a( DOCTOR r PMD ER) START d 3 :1 TIME 10.22 HOW CHOSEN: �"/ TOTALSTANDBY- TIME t;r ❑ NEAREST FA),AILY O TRANSFER _ WAIT TIME � f` ❑ PATIENT DIRECT 13 OTHER' CALL BACK N: AMB LAN E OMPANY: } PT.AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE :Uf— ❑ YES, D NO ❑ WALKED 13GUERNEY•Q OTHERLJ I ' I )`1.' #11q 1! PATIENT CONDITION: DRIVER' Y�/ / (EMT-tA� k ,s TECHNICIAN ` PARAMEDIC Hx: i1- i•i DISPATCHER: I f./!' r. (V 4 4+ , CHIEF COMPLAINT: I'r '• I 1 fir;f ' +'1�1F j`'DRY RUN: ❑ YES W NO REASON FOR DRY RUNrv: ' +• I I •-t 1 I' AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES:(SIGNATURE)X MEDICAL COVERAGE: INDUSTRIAL 13YES 13NO NO.OF PATIENTS: S.S.# PRIVATE INS. CO.: BASE RATE: U!4.1+rr Fj lLel­ �'! ` KAISER#: MULTIPLE PTS.BASE RATE 4..+'•`- i BLUE CROSS#: TOTAL MILES: X MEDICARE#: E.O.B.ATT. ROUND TRIP: ❑ YES ❑ NO .� ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPHP#: EMERGENCY RUN: MEDT-CAL#: CODE 2/3 OTHER: OXYGEN: (PER TANK) I / P.O.E.STICKER ❑ YES 0 NO NEONATAL: (INCUBATOR) • t r=`' �ff�YYY��" DATES BILLED: ?'-" % ' � ' ('� •+��• L'('� S1 STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) ? ; ! NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X fR ' DRUGS: (PER ADMIN.) X .;:';:?:ii NAMEI I i(' 'I i' rr %'RELATIONSHIP! i ' E.O.A.: (IF NOT REPLACED) "" '',M1, sv ADDRESS: I ' t 1 i ' ' ORAL AIRWAY: (IF NOT REPLACED) t CITY: �� '''Ii I STATE '�ZIP,—:JL C-COLLAR: IF NOT REPLACED r" WORK PHONE: DRY RUN: (AUTHORIZED) ? r EMPLOYER: OCCUPATION: OTHER: F ADDRESS: k '•1 CITY: STATE: ZIP: I. ii l COMMENTS: TOTAL — f PATIENT RECEIVED BY:X Ste' I•n•vider xtain Aite mid *'.:'• ropy Art�rn Yelia: ••n o• I•'.: F,�•: i ,(SIGNATURE)' PM - Z^'� � .. CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT / AUTHORIZATION . / Y CHECK OR FILL IN APPROPRIATE SPACES DATE:1 , PATIENTS NAME 1 ( I / M ❑ F. COMPANY N ' r i r + 7 ADDRESS,-1 r AGE /D ' ?t, Z Ll zi- CITY STATE �I ZIP ( �� DOB O Sn M OT ye❑ W ❑ Th ❑ F ❑ DRIVER'SLICEN EN ' PHONEl 11— 33.)V' NATURE OF DISPATCH)�l��R' TYPE OF TRANSPORT: AMBULANCE OTHER 13 / INCIDENT LOCATION: RESPONSE CODE: REOUESTED BY: TIME—(24 HOUR COCK) TO SCENE— /) ❑ S.O. CALL RECEIVED J� I ❑ P.D. TIME 10-8 • C? 7`f: ,. , PATIENT DESTINATION: FROM SCENES ❑ FIRE TIME 10-97 �� ❑ PSAP TIME 10-49 . •ft - MILEAGE: OTHER/PVT TIME 10-7 END Fl G U TIME 10-98 DOCTOR PMD/ER START / �� TIME 10-22 :..HOW CHOSEN: TOTAL ' —jLL STANDBY TIME ❑ NEAREST F ' ❑ PATIENT FAMILY ❑ TRANSFER WAIT TIME CALL BACK A IRECT 13 OTHER 1 N: MByI �E COMPANY: 7p-J�.t PT.AMBULATORY? PATIENT TAKEN TO AMBULANCE: I �,,,, '' ,, RESPONSE ZONE " ❑ YES .W NO ❑ WALKED ❑ GUERNEY• 0 OTHERIL-LLtJ�Li�Lll(( < PATIENT CONDITION: DRIVER _.a• i. .a.' •— EMT-tA� i TECHNICI N "_`/ FFARAMEDIC »S;r Hx: DISPATCHER: , .. CHIEF COMPLAINT: I •DRY RUN: ❑ YES (A NO REASON FOR DRY RUN c .z AUTHORIZATION FOR DRY RUN(EMS USE ONLY) , PATIENT REFUSED SERVICES: (SIGNATURE)X �yyl ?' ''• MEDICAL COVERAGE: INDUSTRIAL 11 YES ❑ NO NO.OF PATIENTS: S.S.N L. L / 10..1 < UJ ,c rl r l�,iri 1"C scO�'}� PRIVATE INS. CO.: BASE RATE: ) Ili`: P. (U L I KAISER N: MULTIPLE PTS. BASE RATE ��' f + BLUE CROSS N: TOTAL MILES: X MEDICARE N: E.O.B. ATT. ROUND TRIP: 13 YES ❑ NO • ' "';;1 „�� l: A ❑ YES ❑ NO NIGHT:(19:00-07:00) , CCHP/PPHP N: EMERGENCY RUN: MEDI-CAL N: CODE 2/3 OTHER: OXYGEN: (PER TANK) y(A P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) ,rz • j 1 DATES BILLED: --L-22 -!.',. / STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY IV.: (PER ADMIN.) X y}� '( DRUGS: (PER ADMIN.) X ;:'.` :p; ii• NAME: I. Lh—?' 1t�Lc01 LATIONSHIP:1( E.O.A.: (IF NOT REPLACED) ;.'.' � ADDRE`5/S "11 ORAL AIRWAY: (IF NOT REPLACED) 4 CITY:SL' + t' (' STATF' '1{ ZIP: L r d L' C-COLLAR: (IF NOT REPLACED) PHONE: f WORK PHONE:_ DRY RUN: (AUTHORIZED) ?r EMPLOYER: OCCUPATION: OTHER: ; ADDRESS: yr CITY: STATE:__.ZIP: COMMENTS:_ TOTAL: •f O PATIENT RECEIVED BV;.,X• !'r ri•{ar mr.:iv Poi to a.i.nr•e% .V•1, Rehr Ye7 iw r, i r.r pL:.: •.:;r.•... ' •.•SSI NATURE) frS-' !6 , i'. !"' .. 3�. ,ji 40 6:/ CONTRA COSTA COUNTY AMBULANCE 1 - �. ARE-HOSPITAL CARE FORM t UNIT AUTHORIZATION N Ct - CHECK OR FILL IN APPROPRIATE SPACESDATE; ,•,: Cola �aur f�c �', Lt�t9 PATIENTS NAME ��_ O M. F COMPANY N '31 a\ ivisqgN JkDDRI AGI CITY ST/CTE ZIP DOB rr n ❑ M O T O W O Th O F' O S DRIVER'S LICENSE N -PHONE MATURE OF DISPATCH V�1� TYPE OF TRANSPORT: AMBULANC THER O (•.:-�:+j# '; INCIDENT•LOCATION: RESPONSE CODE: REQUESTED BY: TIME- (24 HOUR CLOCK)`. i"` -1 [t S 1 TO SCENE- ❑ S.O. CALL RECEIVED :_LL : {31C.c`"• o J S 1. ❑ P.D. TIME 10-8 �� t PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 0 (�_ t` � , w `4 L ❑ PSAP TIME 10-49 � �4{iJ MILEAGE: _- _ER/PV� TIME 10 7 ��� • � END �,%'�.u`S' TIME 10-98. J L_ � � Vit.. DOCTOR L,/A L,L PM 1R STAR TIME 10-22 "' { HOW CHOSEN: �-! TOTAL U �- STANDBY TIME O NEAREST O FAMILY TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK N: AMBULANCE PT.AMBU ORY7 PATIENT TAKE TO AMBULANCE: RESPONSE ZONE ❑ YES�O ❑ WALKED�GUERNEY,O OTHER PATIENT CONDITION: DRIVER TECHNICIAN PARAMEDIC Hx: DISPATCHER: -.DRY RUN: ❑ YES ❑ NO REASON FOR DRY RUN ' } CHI F COMP AI T' �3 1 Q 1 AUTHORIZATION FOR DRY RUN(EMS USE ONLY) .4 1 PATIENT REFUSED SERVICES:(SIGNATURE)X f !t MEDICAL COVERAGE: INDUSTRIAL ❑ YE9-IZ 1� NO. OF PATIENTS: P�IVAlE IN �c�'� BASE RATE: KAISER N; MULTIPLE PTS.BASE RATE 1 •' •� .: �, BLUE CROSS N: TOTAL MILES: ='t`A4 X MEDICARE N: E.O.B. ATT. ROUND TRIP: ❑ YES O NO O YES O NO NIGHT: (19:00-07:00) `. tl •`'� CCHP/PPRP N: EMERGENCY RUN: R•Z-+.�:,.;��N .- MEDI-CAL N: CODE 213 ( , " arra.,`; + r OTHER: OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES O NO NEONATAL: (INCUBATOR) DATES BILLED: La J STANDBY: (OVER 15 MIN.) ; y, E.K.G.: (PER EPISODE) ) , NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X ' �(�•-,� 1T�� WV l,.LL t*j((P?ln n. Rl1 - (� (PER ADMIN.) Xi. NAME:1�1` i RELATIONSHIP E!O.I1TF NOT REPLACED) r ADDRESS; ORAL AIRWAY: (IF NOT REPLACED) b YZ 1\C CITY: STAT ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: ORK PHONE: DRY RUN: (AUTHORIZED) �'}z EMPLOYER: 1 . a 9 COCCUPATION: OTHER: .rr ADDRESS: + ` os• CITY: STATE: ZIP: f 41� y� '`� i : COMMENTS: 1 •r1V •AI L TOTAL: 1Ll v:�:3ni `,� i4'`. PATIENT RECEIVED BY:X Pn,vider mtain Vnite m,i Ylnl Ye7:ew: rnJ-+ n• !•; :h;n (SIGNATURE) EMS-1 CONTRA COSTA COUNTY AMBULANCE r PRE-HOSPITAL CARE FORM 1 UNIT / AUTHORIZATION M ` CHECK OR FILL IN APPROPRIATE SPACES DATE: "` a..-/ /� "�• � (, PATIENTS NAME ( y l�T^^�uouj ❑ MKF COMPANY# ADDRESS 3 11 L 1\��� �i2A ''\,y p! AGE CITY I V�L STATEP�* ZIP � I DOBE' � Sn M ❑T O W O Th :O - � I / DRIVER'S LICENSE# PHONE `%ATURE OF DISPATCH._ TYPE OF TRANSPORT: AMBULANC -ETHER❑ T— 'r INCIDENT LOCATION: � RESPONSE Cp.D E: REQUESTED BY: TIME- (24 HOUR K)� .�s, TO SCENE- ❑ S.O. CALL RECEIVED �j ❑ P.D TIME 16.8 1Ajel i PATIENT DESTINATION: FROM SCENE a ❑ FIRE TIME 10-97 - `_ -' ��4, ❑ PSAP TIME 10-49 j'•r :.. MILEAGE:, THER/PVT TIME 167 END ' TIME 1698 DOCTOR n Ai E- 3 r. PMD R STAR TIME 1622 HOW CHOSEN: ITOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK#: AMBULAh16B• TANY: aC.�.NN .7•' PT. AMBRESPONSE ZONE ULATORY. PATIENT TAKEN TO AMBULANCE: '- ❑ YES�.NO 13 WALKED b:tUERNEV,❑.OTHER a: f� it:`e PATIENT CONDITION: DRIVER QPM C'' MT�+AZ_ TECHNICIAN, PARAMEDIC ^� Hx: DISPATCHER: CHIEF COMPLAINT: C\�A, �''`11 _.DRY RUN: 13YES 13NO REASON FOR DRY RUN µ '•� 4, 0 ' n p1 AUTHORIZATION FOR DRY RUN EMS USE ONLY C[ ' PATIENT REF SED SERVICES:(SIGNATURE)% ".:t_ - °' MEDLCALCOVE E: IN USTRI L ❑ YES--,Q.-NO NO.OF PATIENTS: ' 4 �5 PRIVATE INS. CO.L � �h\t'v�` BASE RATE: '.1:.""" ,: ;tJj h•' ''.' i}♦ • KAISER#: MULTIPLE PTS. BASE RATE BLUE CROSS#: TOTAL MILES: X A v MEDICARE#: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP#: EMERGENCY RUN: MEDI-CAL#: 1 , CODE 2/3 OTHER: OXYGEN: (PER TANK) 1� r/ P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: =j_ice =—� I� /f •F-' j STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.} X DRUGS: (PERADMIN.) Xi� I°': NAME:_ RELATIONSHI `E.O.A.: (IF NOT REPLACED) Its ADDRESS:— ORAL AIRWAY: (IF NOT REPLACED) CITY: ) T— STATE ZIP: _ C-COLLAR: (IF NOT REPLACED) PHONE: �> L4 ] WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP: --- ?Y COMMNTS:- h � � ? "A —1_.—S�'� . PATIENT RECEIVED BY: % 1 F' i...'..___.—___•—. (SIGNATURE) 1. •ci rr• e•�t_. Y.i'� .n:: . . ..�.a F,t;4 rn ic•'. .. ••at a r.• i!•' . ,. !:... EMS-I 101111 I 1ANUL W10 DEMAND NO. 215 ��._. VEN_OOA N0. Il 4 4 D L610 '0 0 /m the Treasury or the �_ COUNI Y 01; CON'FRA COs rA ` STATE OF CALIFORNIA DATE 6-18-82 'Presented By: - CADILLAC AMBULANCE SERVICE, INC. NAY[ (l Aal) (TIPSY) 4601 NEVIN AVENUE_ IMPORTANT nn Re See Instnlctions nn Reverse Side ADDRESS RICHMOND, CA 94805 CONTRACT # 22-079-8 CITY, $TATt n►coot DATE: *17-1-81 LO 6-30-82 For the sum of ***ONE THOUSAND FOUR HUNDRED NINETEEN AND 15/100********Doltors As itemized below: UNCOLLECTIBLES _ DATE DESCRIPTION AMOUNT I�—A_ITACHED f�er0e�: .N r— i c --r— PAGESr ' : 16e3 c u I 7-r7 v/ t--- -- ---- -- ---------' --- such 2-5L71 _1�$2.—: .._ 0 � '.._ _ _I-15. x .'--- ---_ ------- -- ---- ------ - °'� 3v The und-rsigncd nnd,-,r the p!naltp of perjure• !ztatvs That the ahoee claiin and t.ho ileitis as therein set out are true an Ct�grrect; that. uo pi_rt thor.rof lws brl•n heretofore paid, and that the amount therein is justly du. . and th::t tho s m� is presented within one •.car after the laczt ilom th-rR.I! has accrued, Si d Recel ad, Accr.p!ed , and Expenditure. t.ulhor zed _. __...._—.— _ _-. _ IYIL_L} l�.t/JI CCC.P IN:'YT HC 47 D CHICK C[pUl IU —14Z U: J71 —_.•_••••••••••• tl�'YIY�IrrJG�--�• — •••••• C/'•, —ACC C.Ti1--_(%C-Jk)iPA%C[ IT `iC / iY[r Y V •� (..(=�:. r" ILI,r lI/'�� }} 1 AcTTrii: [.ic rLol. olacouMT ._ aUY ACC MO IMYOIC! DAIr~�~��---• Cl ICN,►7!H 'ter l'N C/0.0 UOMT [IIC UY AA A*Cl YD. ./• PA-ME NT AYCUMT _ t UNA&Ir AYDUNI fiat C%l IOU ACTIvITT ..p'7, DnLourT !UN NO• IA•/OIL�D ilj' •�•�_I _ [[CC*1l i::Y— aUMD�CR/. A:CC'JAT INC CN a*A-,[ M0 T/L , IAYY[N/1 /AfI G{IMY � I�1�-.�-.Jr.-L. LSA—i._I+L_.r:.�_.I r-..J--\_.L.� �JJJ -- — _---__� _ ' TAAAt I[ AUOU�1 lAQA 1^IT'Gr� AC 7IVITY Iel[ lAv DIlCOUrT .. CONTRA COSTA COUNTY AMBULANCE 1J PRE-HOSPITAL CARE FORM I UNITAUTHORIZAT Atr ION q `F © ZNECK OR III IN APPROPRIATE SPACES DATE: t /17-7 PATIENT'S NAME r1' low �J(� ___ M ❑ F COMPANY# ' f ADORES 7 i 0 /? C/ AGE = ql CITY V SIC STATE ZIP .f DOBJ� ❑ Sn ❑ M ❑ T ❑ W ❑Th ❑ F S.; . DRIVER'S LICENSE q PHONE /&1 NATURE OF DISPATCH- [ �rZ Y•'r. y.. TYPE OF TRANSPORT: AMBULANCE OTHER❑ ... \ H INCIDENT LOCATION: RESPONSE CODE: REOUESTED BY: TIME— (24 HOUR CLOCK) ePi TO SCENE- ❑ S.O. CALL RECEIVED S7AiJ�JDa2 r��f 3i 3 P.D.❑ TIME 10-8 r -_, - '. PATIENT DESTINATION: FROM SCENE-� IVFIRE N TIME 10-97 s , 'z ❑ PSAP TIME 10-49 IJiFG� J/Oce MILEAGE: ❑ OTHER/PVT TIME 10-7 1_7: 5 1 7 .- END SG' TIME 10-98 DOCTOR ��� PMED START TIME 10-22 'x l .. .: HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT � OTHER S✓ ,rjr i5u� CALL BACK k: AMBULANCE N . r °`:•."/�l . + fPT.YAMBYTORY? PATIENT TAK TO AMBULANCE: RESPONSE ZONE 't ESO ❑ WALKED ;GUERNEY,•POTHER PATIENT CONDITION: DRIVERlov r? Nr EMT-1A 1 TECHNICIAN - 64 PARAMEDICy' / DISPATCHER: _ •,',' CHIEF COMPLAINT: � -DRY RUN: ❑ YES O(NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) 1 ' C PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL C IV RAGE: INDUSTRIAL ❑ NO NO.OF PATIENTS: •:'.L S.S.M PRIVATE INS.CO.: _P-r1iIIZ6 f3l Et BASE RATE: KAISER#: MULTIPLE PTS. BASE RATE BLUE CROSS a: TOTAL MILES: 74 X -2 Po 2- G MEDICARE C E.O.B. ATT. ROUND TRIP. ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) "' 1 CCHP/PPHP#: EMERGENCY RUN: -��'•?- .': :7f w MEDI-CAL C CODE 2/3 F OTHER: OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES ` NO NEONATAL: (INCUBATOR) -'I - F. 1 - ' 1 - 1 STANDBY: (OVER 15 ' :•' DATES BILLED: -14- -if MIN. �ELI1i Z ) _ _ E.K.G.: (PER EPISODE) - N. NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.' (PER ADMIN)_ / X _LSl>>L-'- L:i..GQ"" � �'�y ; 9,. f� (� DRUGS: (PER ADMIN.) X �!/ NAME: Do I` 0ES (�1( 1,'')r'--/ RELATIONSHIP:L.LL.Le-- E.O.A.: (IF NOT REPLACED) ADDRESS: �� —_ ORAL AIRWAY: (IF NOT REPLACED) CITY: J _ STATE__ZIP: C-COLLAR: (IF NOT REPLACED) PHONE- WORK` WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYERUN OCCUPATION: OTHER: :;t1 -14 ADDRESS: (� CITY: +[� r,^UI`IJ STATE: ZIP:__ — z, COMMENTS:_ _—_//_ _ PATIENT RFCFIVFD BY:%_ +' rr•.i am mai: Yni rt --'----.- _. , , (SIGN IN �'•'�. ... ..•.r Frt�r^ )_: ..I.•... . EMS-1 •�j _ P N0. A • 111:�11:1�v1) REP,�I��d��'d Uth1;;NU W . ZI8 1 ' VENOU •L�c }f, 4. 4 D �� ILJI on the Trear:my of the COUN'I-1' 01; ('ON l RA ('OS1 A 6-18-82 Presented By: S1W)1: OFCAI.IFORNIA DATE CADILLAC AMBULANCE SERVICE, INC. ----- NA,Y[ LLA,r) vINATI ' 4601 NEVIN AVENUE IMPORTANT Scc Instructions on Reverse Side , ADON[!7 RICHMOND, CA 94805 CONTRACT # 22-079-8 CIY, $TATE lip CODE DATE: 7-1-81 to 6-30-82 *********FOUR HUNDRED SIXTY AND 00/100**************** X69 fin For the sum Of Dollars As itemized below: DRY RUNS . DATE DESCRIPTION AMOUNT i U SEE ATTACHED Ana qMe� -----. -- --- ----------- - i X19 — — PAGES tc pU'L ar/L --L- -Lt�w•-•��_l���a�..---f�u.c••—err���,G�--�L���2 _�y�. T — -JUN.2 a _ ---- Emergercy K di„ The m0rrsi,ned under ti!e pert °.ltv at pe:rjur;: stags That the atx)v-� claim and the ii.em5 its therein set out are true and correct; that no part ilivrenf has hl•er: !r ictnf lr' Laid, and that the ame;uit therein is justiv due..and that the same is presented within one tear after tell• last item thwr6f ha!; acf!ri X11. sign Clt .,------_-___--- -_.-.-:-...---_----- -._--- - :., • ,; v: VE. DCCtt O. Received, Accapfr!! , r.rd Expenditure ^ethor.ced i-� - C[T,iTY[NT HEAD CN CMI(i Cf.VTY t--!��� / rt h •u�. aV I = �f ��QT�TfT71 '� —• •-.—•r�••_� -w 4 J �Y ACc 4U A-1 r'CUYt� ke 11-.. rIC pITYta 4MOU , 7' t L \ l I t /'AY• l r Ypr TT r3ri3171 ITdiTTiTY l)T[?TLN7. , 011000NT tYN, N0. INVGIt! DAI{ ,-- Ili ecolpT ION 'S rUN a/0,,A AC CC WIT [NCUMNNAIrC[ 60. riC rATM{NT AMOUNT 1T1 1 TAT AtI� •MOUNT TAIV OFTM9 ACTIVITY OgCOUNT 1'UM NO IN YOIZ[ p [UND/'JCA ACCOVNT [a CtivtNANC[ NO ► C PAT Y[NT •MOUNT W r �'� 122; �•�J`%-3_A_a.-'_+_.1�-����`�— TAWANII AYOUNi .r-iA a Ci TI O�TIVITT $,I- I1/f O17COUNT I • . :1:. CONTRA COSTA COU AMBULANCE • �f ��, a PRE-HOSPITAL CARE FORM 1 UNIT PpAUTHORIZATION w s-- ♦' CHECK Op FILL IN APOPR11TE SPACES DATE: ax) -�S •/i,) PPTIENT'S NAME ❑ M ❑ F COMPANY#_ 5' .• l ADDRESS AGE =;;: .CITY_ STATE ZIP DOB ❑ Sn ❑ M ❑ T ❑ WTh ❑ F ❑ $ DRIVER'S LICENSE M _— PHONE NATURE OF DISPATCH `TYPE OF TRANSPORT: AMBULANCE❑ OTHE INCIDE T LOCATION: RESPONSE CODE: REOUC� ESTED BY: TIME—(24 HOUR CK) �. ( X x; ( TO SCENE- ❑ S.O. CALL RECEIVED / l 7 1 / ❑ P.D. TIME 10-8 PATIE T DESTINATION: FRO S NE- ❑ FIRE TIME 10 97 L '' ';ax.�.ri• L' :,j) �) ❑ PSAP TIME 10.49 S Cfi MILEAGE: OTHER/PVT TIME 10-7 ENDS TIME 10-98 DOCTOR PMD/ER START—=` , TIME 10-22 +`t ti• HOW CHOSEN: TOTAL STANDBY TIME ❑ NEAREST ❑ FAMILY ❑ TRANSFER WAIT TIME. ❑ PATIENT ❑ DIRECT O OTHER CALL BACK#: AMBULANCE C/KPCCANY: ,f , PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE ❑ YES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER PATTENS CONDITION: DRIVER ��-� r I T. gsl TECHNICIAN £ ' PARAMEDIC Hx: DISPATC R"'ems c-,'�' i��' " y , � QQ•�� y CHIEF COMPLAINT: DRY RI I L3-YES NO REASON FOR DRY RUN < AUTHORI T10fJ FOR DRY RUN(EMS USE ONLY) j. .i' PATIENT REFUSED SERVICES:(SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YES ;NNO NO. OF PATIENTS: S.S.0 PRIVATE INS.CO.: BASE RATE: 41, _— KAISER a: MULTIPLE PTS.BASE RATE ' BLUE CROSy a: TOTAL MILES: X - MEDICARE#: E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) :.y'i:• CCHP/PPRP a: EMERGENCY RUN: MEDT-CAL 4: CODE 2/3 "'r .,r, OTHER:_— OXYGEN: (PER TANK) P.O.E. STICKER .IVES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/R SPONSIBLE PARTY: I.V.: (PER ADMIN.)_ X DRUGS: (PER ADMIN.) X NAME:_ RELATIONSHIP: E O.A.: (IF NOT REPLACED) ADDRESS: — ORAL AIRWAY: (IF NOT REPLACED) CITY: -_ STATE ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE:. DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: ZIP:_ COMMENTS:_ — .'.:.dfr �•J ---'---'--------._..----'------- ------- .. VAI; PATIENT RECF.IVEDBY:X 1.�...�.5v r•.r. La:i r:i . . . �q,p rnrar: T.:t::•v' ., rr 50: :4,. �;, (SIGNATURE) EMS-] .. �� • Ei ��VENnOA_N0A,'C, DEMAND NO. 221 �, 111:11;1�1) . r on the Tien%ieq of I Ii• C011N fl' III' ('UN I RA ('OS FA I esented BY: SIMEor' CALIRMN'IA DATE 6-18-82 CADILLAC AMBULANCE SERVICE, INC. �� = JL NAY ♦I II INLrI . � 4601 NEVIN AVENUE Instructions � •` '' •' ' ' See Insttuctiunx an Reverse Side ADDRESS ... RICHMOND, CA 94805 CONTRACT # 22-079-8 CITU. [TATE ZIP coot DATE: 7-1-81 to 6-30-82 L4 For the sum Of ******FIVE HUNDRED TWENTY AND 90/100******************* o Dollars As itemized below: DRY RUINS DATE DESCRIPTION AMOUNT Ou" 2 e_asa2 -- - SE CHED Gm�r ency htr dica';ervtc -- --- j PAGES u - --- --- -- � A ;i_ �' c�, RFCF1 C ----- — ------- ---------- -------••Er.:crgencYfded' �I-Strvices--- T'he undersivnrd under the lwnalt% of perjnry state- : That the above claim and the items as therein, set out are true and correct; ,hat no par, thtaror has been heretofn:e paid, and that thc amount thetein is justly 1^^,'and that. the same is presented within one '.ear after rhe I:!st item the:enf has accruml. VENDOF M1D. Receivrd, Accepted , and Eyperditure Avthn ozed •JA FA MLNT NCl^,S1 C41EI�OEPWTT2. .-- - luw-Ild — QjT e�E� �I �T�IEr'0 A C C Cv'N CFEUNL4i NM0T. V C N U 141 iJti4% k'c.� �.i� '�" 'al I�.r' / „a�.7 L S`f; �l._ � — `"''' `�'�—�" 1*rf?: AII M. r'T�ia �f13N Ac rIi-- iG rinT' DlscouMT 0 1L_ > .. 1 I IUY'M0. IN Voice DAT[ VI LCR II TIO■ FUND OMI. ACCOUNT INCUMBRANCE no. IFC FATMIMT AMOUNT TJBABL AMOUNT TLII "TIDM AGTI MITI • DISCOUNT 1 t . ,UM NO. 1"Voici DATF ter" OI TCN7110� —ter - iFUM7CA B. ACGWNT [MC VYBNANC[ NO 11FC FAr M[NT AMOUNT ' TAI ABS[ L•AOVMT MIN L•TION ACr IVITT I11: ILL, 01 0 1Ir 1 (DIS P„ 7/771 r , f }L rte, t; r jY. `l,Part`�I J ' CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FOIS UNIT ® AUTHOR ION N� ? k! v,,. CHECK OR FILL IN APPROPR/ATE SPACES ^ r DATE G— , [Y PATIENTS NAME31b; 110"` (��il 5 1 r► CZ flll0.1 S O J ❑ ❑ F:' 4 r,,.. M COMPANYM jij•,, I , ..` a. t 11 51" ,c3 , j:: k••rL til•�,K,°,r.C.,�` ADDRESS � � AGE t r CITYN:, a>}� STATE ZIP DOB �Sn -❑ M..!0 T ❑W*❑Th�❑ F O S { DRIVER'S LICENSE N r " 1t PHONE '' " a NATURE OF DISPATCH' TYPE OF TRANSPORT AMBULANCE OTHER E3. tieJJ .v..-�i.� 1I 1 �•T •1'y(] 'Y,",t�•-qL�h•' . f" "f ISJ N• '"��'i'` J e,itE tT y y {I�{`' 1• '' i�"rr ��fii t '.X4 •:-.i+ `a .. .'., ` INCIDENT LOC�TION�b r. . . , ; RESPONSE CODE4b REQUESTED BY jTIME (24 HOIi So, K). { TO SCENE` i;' 1 f ❑ S.O'' '. . .?CALL RECEIVED?�)T� r1we. {:, + - ❑ P.O�' tTIME10-8 tPqL TIENT DESTINATION .'. t t ! Srli x FROM SCENE�31r` � ; ❑.FIRE ;TIMESIO 971y. ! +. ❑ PAP'' TIME 10-49 �iK a 4y T\ MILEAGE 'r�P TOT HE ' PVT + 'jTIME^10 7+ ENO J ._ + .{TIME 10.98)f+t s'!s., r DOCTOR PMD/ER '. START. rf 'i :TIME 10-22r�[ r- .. IL HOW CHOSEN �i t ?.• TOTAL y _STANDBY TIME i"❑ NEAREST J ❑ FAMILY ❑ TRANSFER ..WAIT.-TIME� wt ❑ PATIENT •. ❑ DIRECT �THER (�� < CALL BACK ° AMBULANCE CO YYF ��tt,f F�YAMBULATOAY4;' 'PATIEN�TAKEN TO AMBULANCE:Y1�j 'r?j• , ,�*'''r? ta" aRESPONSEZON S ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER PATIENT CONDITION ; Y 3 f .;'DRIVER j ,., +1{; , iw <"'i•'{',.. f F . ,, • > i .. .EMT to jj.� J T` •n " { TECHNICIAN PARAMEDIC 'Hx. - ..,•• j .�•;DISPAT IjE �;� ✓� . : .,, ,', Cy..,Y:a+li t, i-r 'CHIEF COMPLAIN �� yv. "'' DRY R N:04 YES ❑ NO t'REASON FOR DRY.RUN G' S •• Zir ;:t•�- rw r�' r., UTH FOR DRY RUN(EMS USEONLYJ •' r•. •••'I ?,�.7 td.- Y" �•.rt'�11.f i.a.3+f,. . PATIENT REFUSED SERVICES:(SIGNATURE) X " , { MEDICAUCOVERAGE t INDUSTRIAL '❑ YES\.❑•NO NO*AF PATIENTS:-.'; A S.S. fl writ J• i PRIVATE INS CO.: x�H BASE RATE KAISER 01" ' MULTIPLE PTS:BASE,RATE BLUE CROSS tl TOTAL MILES. X t • aS x t ";;v1EDICARE 8 E.O.B. ATT. .ROUND TRIP:"'❑ YES ❑ NO AJ {�� y°x �1� .❑ YES ❑ NO 'NIGHT: (19:00-07:00) Z ,CCHP/PPRP M EMERGENCY RUN 'f 1 { ' .MEDI-CAL#r .,5. �!'�it'. ); �i�1•TY.IE pIS:`e`Ytti' �• T ' r CODE 2/3 >r *; >1` y.^� �Jj r«`. '?OTHER: OXYGEN:'(PER TANK) :7 + ,y tik r h,)r 1, -• �"t r�r �. STICKER ❑ YES NO 'r` 'NEONATAL (INCUBATOR) ' DATES BILLED: STANDBY: OVER 15 MIN.) ( .e�• jot i'' e.... _ V 'f.: k s•,f,tN' `.r, -.,.y •,�N < E.K.G.: (PER EPISODE) °{ t NEAREST RELATIVE/RESPONS LE PARTY:_.«.,, ( t +y I.V.: (PER ADMIN.) X DRUGS: (PER ADMIN.) X .3 ,NAME: • RELATIONSHIP E.O.A.:(IF NOT REPLACED) Xf 5:ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) '* CITY: TATE ZIP C-COLLAR: (IF NOT REPLACED) PHONE: WORK ONE: DRY RUN: (AUTHORIZED) <f3 F ,. E7APLOYER: OCCU ATION: OTHER:.... :.:'. ~ • eL!` a ``,i +, ADDRESS: t' r; CITY STAT ZIP IS COMMENTS TOTAL:- PATIENT OTAL PATIENT RECEIVED BY:X Provider retain White and Pink ra py . Aitum 1r12ov Copy to IMS when billing (SIGNATURE) pts 1• • ' `., I I ANU CUP DEMAND NO. 225 T-±06 V_TNOoP NO A/t • III'.�Ir�NI) l A D r O �� 11 not lite Treavury of the l 5 1_l ..LLQ u ('O(IN1 V OIf ('ON I RA ('()S I t% Presented By: SI'AIF ill• CALIFORNIA DATE 6-23-82 ' . CADILLAC AMBULANCE SERVICE, INC. NAVE uA.T) --- n•aln IMPORT ANT 4601 NEVIN AVENUE See Instructions .,n Reverse Side LODa[!7 RICHMOND, CA 94805 CONTRACT # 22-079-8 st:. tnT, trari [n Coo[ DATE: 7-1-81 to 6-30-82 - - 1 .. For the sum of *******ONE THOUSAND EIGHT HUNDRED TWENTY FOUR AND 20/100** = D As itemized below: UNCOLLECTIBLES DATE DESCRIPTION AMOUNT + .1 _ _ _ _ _... _• _. ... -- – -. _ . rnRWARDE EA — A D .. T?p %"e SS�F A_TACHED re:fir.;_ !�,r• U PAGES .iUjA . 1(,(!�� 1 !tom J ;/l>'u ?y al g k hrZ�F L�-- --- —'----- ---i-– / —_- 12 .'71 2- The nndersi{ nf,(1 mw,ti Illy pi Haig' cit pf!rjur; :;tat(,- : That the altm ,t claim and thr items as thereili set out are true and correct;; 'h.lt too part flwtru( h,(,; br. c t:( n't(:t•.tr ' p:ud. and that the amount therein is jn 'r dlie, and that tlic same is presented within one t'ar atter i 1 kur r 1ten, ilwi(';11 Ibis al'Crnad. VEN GOR PIC'. Pecel.r:I .'t[CP.C'Pd • Ond E ,rf ndlture Aufhcfu7 'd ' - • ' - , !� J ---+._.-__. .�.:_.np on RT Mf Yi NE LO.CP�jriE.e GCrUTY - J rYrL-�tT r ) -'—//�-•�"—�11t:r tilZ7itR1 ,I yT 1(;yS � L(:�fOJ4 liCUMIAAk T NO PIC -OATw M AMOUNT �':��.— .mss -._I�.._:—.__._� • ,+ '—'-��YSii�+l}i-5 w T.i4 LiietiV1T i'[c ris7 DISCOUNT r _ 1 TVM. NAT7'VQ' f;7t -"�'-"'�- -- D[[Ca1r T+Ca+W VU'40'r'l• AC LCVA7 [wCUNMLwC[ N0. r/C PAYMENT AMOUNT 11 1 ._`W _Lia_ _ •_1.—.- _ .. 1 PAI L/I LMUVNT 1 tL�La�OPLON aCT1Y171 OIL COUMt IVM NO INVUCT pAi� N1L(a1PT.:• PUNDJOaI AC•:.UNT INEUULNANC[ wo r/e payment A 0 ___ ._ I_ - _� _- 213 1 i TALLtI /MOUNT lAlt NnCM AC TIf II% VAC fl-l> DIlCOVwi -_- I- 1 _1 r '- - ' (015 Rlv V.7) r CONTRA COSTA COUNTY AMBULANCE / Alf, }ARE-HOSPITAL CARE FORM I UNIT AUTHORIZATION# �-JT CHECK OR FILL IN APPROPRIATE SPACES DATE I PATIENTS NAME_ i 1 % % � nM ❑1 F COMPANY# t ADDRESS i ) CITY STATE / s ZIP DO " '" LO Sn ❑ M ❑T ❑ T►1 ❑ F ❑ /! ? .fit' Z/_� • DRIVER'S LICENSE# PHONE 0 ATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE O OTHER❑ c I INCIDENT LOCATION: RESPONSE CODE: REOUESTED BY: TIME- (24 HOUR CLACK) ; r' I TO SCENE- _ ❑ S.O. CALL RECEIVED j " y1 r 1 ❑ P.D. TIME 10-8 PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 10-97 ❑ PSAP TIME 10-49 f . MILEAGE: 7 [�OTHER/PVT TIME 10-7 rL� y Au t 1 END <r TIME 10.88 DOCTOR `` ' PMD/ER START3•f' (, 1 7 ) �' TIME 10.22 . . ' HOW CHOSEN: i TOTAL I ° !� STANDBY TIME I .,;...:,;. ❑ NEAREST ❑ FAMILY jCI.TRANSFER _ WAIT TIME " ` ❑ PATIENT ❑ DIRECT ❑ OTHER I CALL BACK#: AMBULANCE COMPANY: "y��j�Y 1>' C 1c y k, PT.AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE ' YES ❑ NO DIWALKED ❑ GUERNEY,D. OTHER `r �..r. .,. :i F jr,;:'PATIENT CONDITION: DRIVER EMT A, (1 TECHNICIANARAMEDIC HK: .. 1•. Z..' DISPATCHER: moi.'' CHIEF�OMPLAINT:I t, -DRY RUN: ❑ YES ❑ NO REASON FOR DRY RUN ^.,•`; AUTHORIZATION FOR DRY RUN(EMS USE ONLY 1 c: ' PATIENT REFUSED SERVICES:(SIGNATURE) X A • ;' ' ." MEDICAL COVERAGE: INDUSTRIAL DYES ❑ NO NO. OF PATIENTS: S.S.# [� 1 ' PRIVATE INS. CO.: BASE RATE: S��.35-_- •.. � .� $sE:.fC KAISER#: MULTIPLE PTS. BASE RATE •'�{��i;>' BLUE CROSS#: TOTAL MILES: X a, An MEDICARE #: E.O.B.ATT. ROUND TRIP: 13 YES ❑ NO ❑ VES ❑ NO NIGHT: (19:00-07:00) 1Z' CCHP/PPRP#: EMERGENCY RUN: y• �o ::•}%.:' MEDI-CAL C CODE 2/3 �` ":' �• F'".; OTHER: OXYGEN: (PER TANK) z ?;= P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) •�. •;,�� �. ,� , DATES BILLED: f..'. , _ ��l _.j L• /a• - f_ J STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X l / DRUGS: (PER ADMIN.) k •::•'q} •+_,pL NAME:_.- ' • RELATIONSHIP:)' '- �,' E.O.A.: (IF NOT REPLACED) h:` ADDRESS:Y _ ORAL AIRWAY: (IF NOT REPLACED) CITY: - - STATE ZIP:_ C-COLLAR: (IF NOT REPLACED) •f' '• PHONE: WORK PHONE:—.__-__ DRY RUN: (AUTHORIZED) EMPLOYER: -_ OCCUPATION: OTHER: r±ti'v ;eF ADDRESS: - ';ts;er't)' CITY: STATE:_-ZIP:-- t?ACI COMMENTS'....------ ------------ ------- a�.`p:>� , TOTAL:_L: i, ,.' 1.. PA N ErEIVE . _- !'�- - TIE T R F D RV' X •' , T. ..:.ley. r,r,�- -v (SIGNATURE) FJ15-1 1 i � CONTRA COSTA COUNTY AMBULANCE •� i' .:;.;;'(� ' PRE-HOSPITAL CARE.FORM I UNIT AUTHORIZATION N-,�I1�/�I CHECK OR TILL INAPPROPRIATE SPACES DATE:.`_ .a . . ��1 ,,PATIENTS NAMEY�.LL 1 V C� 4A 4' / � �%— �❑� F� COMPANY M �,�::;i:•t, ADDRESS lD VU1.v1� Sw AGE CITY ` ESTATE ZIP_. DOB 1O+J� Sn ❑ M ❑ T ❑ W ❑Th ❑TA� =r DRIVER'S LICENSE f1 PHONE2- 3`1- O3 G7 A�SFLK '.NATURE OF DISPATCVTYPEOFTRANSPORT: AMBULANCE BOTHER❑ r;i$c �f r. z�+ INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR C}O�CK) xr . Vis. `_ `� TO SCENE ❑ S.O. CALL RECEIVED " —LS 1 ❑ P.D. TIME 10-8 j�p0� I 1 (, PATIENT DESTINATION: FROM SCENE- ] ❑ FIRE TIME 10.97 v >;•s 'l TIME 1 r0.49❑ P /� _ . ;- MILE GE q_ o OTHER/PVT• TIME 10-7END TIME 10-98DOCTOR 1� PMD R STAR TIME tp-22 HOW CHOSEN: TOTAL STANDBY TIMEj_;; . L' ❑ NEAREST L7 FAMILY TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK#: AMBULANCE COMPANY: �S : PT. AMBUL.6TORY? PATIENT TAKEN O AMBULANCE: RESPONSE ZONE ❑ YES,,12rNO O WALKEDUERNEY,0'OTHER ` *•`. PATIENT CONDITION: DRIVER— M� EMT-1A ,,) ( CHNICIAN�_ PARAMEDIC Hx: _ F �� S I�r'AC.\3—"DISPATCHER: � l• • �- i_ 1U4•r' CHIEr F COMPLAINT: 'DRY RUN: ❑ YES VNO REASON FOR DRY RUN Y% IV in �' '1 (' AUTHORIZATION FOR DRY RUN(EMS USE ONLY) �d t PATIE T REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: INDU TRIAL ❑ YES�O NO. OF PATIENTS: _.��1 • ' S.S.« oN PRIVATE INS. CO.: N1 US — BASE RATE: � � •' r KAISE' MULTIPLE PTS.BASE RATE ' BLUE CROSS p: TOTAL MILES: 0,2 xt X 2 JPoayY: s Z; . • n, f MEDICARE k: E.O.B.ATT. ROUND TRIP: 13 YES ❑ NO �•� 1.�. ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPHP p: EMERGENCY RUN: j. v MEDT-CAL#: CODE 2 13 OTHER: OXYGEN: (PER TANK) - t• , 1. t P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: - -s.2 .S -I x/ 6 LL t ) STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY. I.V.: fPER ADMIN.? X " '"`✓, DRUGS: (PER ADMIN.) X +•-E: ; ; NAME:_t t>�� `��IA k RELATIONSHIP:!!,e 1 E.O.A.: (IF NOT REPLACED) (!: '<tj ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) +. f CITY:_ STATE__ZIP: C-COLLAR: (IF NOT REPLACED) !' PHONE: WORK PHONE:_ DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: iF ADDRESS: .•: � is.'..t CITY: STATE: ZIP: COMMENTS:---.- --- �:; n• TOTA L: t '.. .-----'---- PATI V R.. r ..� .. .! ----------.._----- ENT RECEIVED X 1--- F'--ride• )•r••.^s y.;;:'r •.:i !:'•u' r:'�;. Fr n, y, ,y,. ., (SIGNATURE) ,EMS-1 — _�. --- - ._ ---. -•-- --- -- �E��6����r�� t CQ Et•IANU N0. 226 veN, ,DonOn3i �(5 • U1.?N(ANI) p� 6 0 ,� u on the Tren+ury of the COUNT Y Of- ('0N7'ItA COS'FA Presented 0y: STATE OF CALIFORNIA DATE 6-24-82 ' CADILLAC AMBULANCE SERVICE, INC. NAME II.AaT) 111"571 IMPORTANT i) 4601 NEVIN AVENUE See Inst(uctions on Reverse Side ADDRESS RICHMOND, CA 94805 CONTRACT # 22-079-8 CITY. STATE :n CODE DATE: 7-1-81 to 6-30-82 f For the sum of. ***ONE THOUSAND SEVEN NIINlIREII EQURTFFN ANN f15 f1M***** Dollars $47 As itemized below: UNCOLLECTIBLES DATE DESCRIPTION AMOUNT _ �--fit`— . -- — ---- --- ---- ---FF. ATTACHED- PAGES T ----- -� .-_ --� t TAC,HED c Rte S •1erVi r. t L. EECEIUED C— TUrT, 2 , 4,21.2-3)0r'1 '3 �3 ' 21-1 :716 a�q 4239 2/2 6 Emergency `yAfedicalServ;g -�W4/;-�'}-. .1.x - 1 l�t.>>tTy— i� .c,/i � cr�ut j�-- The undercit;ned under the pen!Atyof perjury sates: ,at thea to clam, and the items as therein set out are true and correct; 'hat no part therenf has lvw;, lo!WoElte paid, and that the amount therein is ju%ly e, and that t e same is presented within one i. ear after the last irem thereof has accrued. " ✓ / - Sipned .131r:fl � ,n��--•'1'_�- _ VEN DOA 1:0. :r•:�•' `- � � �. Receive J, Accepted , and Expenditure Autherized•�'' "" ._.�. -Y.7+-6- i 411111A r I � fin ,: �1� n c rlTr Dlacourr ' 1 � '1 tJl eoec rtes. rVY. NC. INTOICE OA1[ - CIJCRIP7iO11rW' ��- ♦—MO ON e. At CCJNT ENCUYaRAYCE No. +/C • ►Ar PENT AMOUNT f 1 1 Y -T Duty 1AAA OI110M ACTI r1Tr DISCOUNT 1 'JM at. 1"Yal CT'r�t.-Ttl_' -y�� P[ECRII'T1oN .UMDTOxe AFC-VU T E)IOUYI/1 NCE NO. NC ' .ATMENT AMOUNT �7.. -T — - 1 �J..i-1._I..A.-ll..L_.4..)...�..1..:....a—� —•1:II ALI _ — [ •no acn)In olacuuR AMOUNT TAS■ ('FTIOM1 a/Ic HN! .;A - o.. • CONTRA COSTA COUNTY AMBULANCE f '.( .7 a PRE-HOSPITAL CARE FORM 1 UNIT AUTHORIZATION 0 ' "s ,•,r CHECK OR FILL INAPPROPRIATE SPACES 1 DATE: '�` �•—' F PATIENTS NAMEL I ( (f'flit 1. i it M jl r, t / 1 l ❑ F COMPANY N ADDR SS �iI7 f[:_>`'. ..�. { f��I AGE y +. Ri`„ CITY lSjATEZIP/ [ t DOE11-4k&b ❑ Sn OM OT- OW ❑Th; ❑ F Jlk5S, { DRIVER'S LICENSE N PHONE NATURE OF DISPATCH i � + -W TYPE OF TRANSPORT: AMBULA�NCEA OTHER❑ I INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME—(24 HOUR CLOCK) f ` r { TO SCENE- J,. ❑:S.O. CALL RECEIVED i I7;P.D. TIME 10-8 % PATIENT DESTINATION: FROM SCENE- ❑ FIRE TIME 11 97 S .k ❑ PSAP TIME 10-49 r� r / so l':r/ !!` 7(,� MILEAGE: 1 OTHER/PVT. TIME 10-7 •.r•, t ; END TIME 10-98 si C DOCTOR I / ` I PMD/ER STAT I; I TIME 10.22 Rrn .HOW CHOSEN: ' TOTAL — STANDBY TIME v y. ❑ NEAREST s7 FAMILY � TRANSFER WAIT TIME s . ❑ PATIENT ❑ DIRECT 13 OTHER �I! ! CALL'BA_CK N: AM BU jANCE C0 F�NY: PT.AMBULATORY? PATIENT TAK€N TO AMBULANCE: i ' RESPONSE ZON t.+ 3 ji YES ❑ NO ❑ WALKED u GUERNEY.Ll_OTHER �jlj Fey 'PATIENT CONDITION: DRIVER ( i�r EMT-1A 21 ItTECHNICIAM (! l 'IiAR711ulEDIC s yj 7 Hx: ` PIS`'FATCHER: ) L. ,. isf . ff 4Kyn H EF CO PLAINT- ' DRY RUN: •❑ VES t b NO REASON FOR DRY RUN 4 {. 1��, ip(�I o 'IAUTkIQRIZATIONFFOd DOY RUN €MS USE ONLY),! PATtEN f REFUSED SERVICES:(SIGNATURE)X y' MEDICAL COVERAGE: I`INDUSTRIAL ❑ YES ❑ NO NO:-OF PATIENTS_1-_ -. FEl S.S.N 1 PRIVATE INS. CO.: BASE RATE: E' KAISER N: MULTIPLE PTS.BASE RATE i ''. BLUE CROSS N:y'. ' %_�' / TOTAL MILES: X Etta v MEDICARE k: E.O.B. ATT. ROUND TRIP:. 13 YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) n_ u CCHP/PPRP N: - EMERGENCY RUN: �� MEDI-CAL N: CODE 2/3 i OTHER: OXYGEN: (PER TANK) < P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: - - ' '/ !! - t i, r STANDBY: (OVER 15 MIN.) , i'.•" ,( g— s,�P tf- E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: fPER ADMIN.)_ X ) DRUGS: (PER ADMIN.) Xj; NAME:' I I 1 ' RELATIONSHIPLL LI � E.O.A.: (IF NOT REPLACED) ADDRESS: ' t — — ORAL AIRWAY: (IF NOT REPLACED) CITY: I' STATE ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: ! OK PHONE: DRY RUN: (AUTHORIZED) .' EMPLOYER: OCCUPATION: OTHER: L4t ADDRESS: CITY: STATE'—ZIP: COMMENTS:---___ _ -- —�•--- TOTAL:---.1LIS'—4 w, ----_--- — —` PATIENT RECEIVED BY X.,.4�g1 (SIGNATURE) • .. ;.L....,.nr• mr.r.< KnI Ir .:;. .•ta-� R. . ta I^ rS' . . .. '•'.1 gra �I W,.;E COPY �, • DEMAND N0. 244 Fv 4 4 6 0 0 3 on the Treasury of the a, ('UUNI Y OF CONI RA COSI A 7-8-82 Presented By: S7AfEOFCALIFORNIA DATE CADILLAC AMBULANCE SERVICE, INC. NAME (INT) IFINITI - - IMPORTANT 4601 NEVIN AVENUE ties Instructinns on Reverse Side AOOAE31 RICHMOND, CA .94805 DE CONTRACT # 22-079-8 1' CIY. STATE LIP DATE: 7-1-81 to 6=30-82 For the sum of ******ONE THOUSAND THREE HUNDRED SEVENTY THREE & 05./100Vottors $1:3?-3-9rr- k j As itemized beto-N: UNCOLLECTIBLES . _ _ DATE j �DESCRIPT40N AMOUNT t T-nnWARDED �FjyF 4C--,�M _ S_E TTACHED eU — �PaqeS 1 V76r-20Wl,2DSS AV 0 �'�zf�cl�rtt o; ^� �1,�. �.��.��-�.�_��-�_.c�:_;.--�•,..�,��,�tcB:IL._r"'"7------------ U The undersigned under nit- penaity of perjur. states: That the above claim and the items as therein Set out are true and correct; 'hat nu part then•of has bel-n hcrf•tafnre paid, and that the amount therein is j.t§tl� due, and that the s,}nw is presented within.one ' year after the last item thcreot has arx.ue'.1. •� -- ��F Sigswd —-- —_— -- — — — ------��— — —I " VEf100R N0. Receired, Accepted , and Expenditure Authorized c'I PAiTY[MT MEAD OP CN}Ef.CEf Yrf l0 TVG.Ti6 1 a VT{E�iiT 'YUxG73ii" "Tt. I "cum"ik"tTiT[w3' ric t TM M u Iq 7 a 1 TtE# t. / n e Tv Disc tt� Y 'T T -ITT– •rlt ►�/!, OYNT IUM. NO. IMY01G3 GATE us I:RIP IUP flu"C 0N. •<CCYNT ENCbMAA AMC& M0. C PAYMENT AMOUNT 1 1 ANANI AMOUNT PAN■ OPTION Atil Y11T t DISCOUNT 1 , NUM N0. IMYOL'1 S-ITT .,._—.�..._....•.._...Oi iCM{jT WM" PUNOi 04• —ACCOYNE ENCYMERApCE MO P/C } PAYNE NT AM Y TAx ANIS ♦MOUNT TAI CrTrrl ACT$ ITE LI-IC IU! �---.-. ___.l_ _ _I.---�- ----._T��� . _ -_:� v • ,'e + • CONTRA COSTA COIR AMBULANCE • r PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION N 2 070 r�cn %: � CHECK On Fllt IN A/Pr10H1Ut it _12- 7- TE SPACES � DATE: PATIENTS NAME r l_)�_ I L XM O F COMPANY N L-S'Y :ADDRESS �L1 ) "? j7i, 1�4a r�r )fr. AGE—,�._ �M.:. . } CITYt �t^•: ' -�° STATES..1�5+1_ZIP DOBC -� ❑ Sn O M 0 T f? W O Th O F O S , i {E DRIVER'S LICENSE k PHONE�.ti NATURE OF DISPATCH y� y,� TYPE OF TRANSPORT: AMBULANCE 0 OTHER O f r L {[ 'INCIDENT LOCATION: RESPONSE CODE: REOUESTED BY: TIME—(24 HOUR CL qK) r ' TO SCENE- 0S.0. CALL RECEIVED /u 6 f s P.O. TIME 10-8 PATIENT DESTINATION: FROM SCENE- a FIRE TIME 10.97 ` r t D�SAP TIME 10-49 { 2 Z l' 11 ,`► I f: r, MILEAGE: THE P�V TIME 10-7.. !!� END r� s TIME 10-98 { DOCTOR- HOW OCTOR AlLlil[FG START 1 iz{_.�Zr IL [ TIME 10-22 HOW CHOSEN: - TOTAL f (! ! —� - STANDBY TIME 0 NEAREST 0 FAMILY TRANSFER WAIT TIME " !. 0 PATIENT 0 DIRECT 0 OTHER CALL BACK to: AMBULANCE COMPANY: C' i�. PT.AMBULATORY? PATIF,NT TAKEN TO AMBULANCE: RESPONSE ZONE +' 0 YES 0 NO 0 WALKED 0 GUERNEYr❑,OTHER $A?; , — PATIENT CONDITION: DRIVERFM[ T-1A TECHNICIAN PARAMEDIC ;« Hx: f !)'/ )?i• �_T •i t [A i t� t✓ DISPATCHER: ( t CHIEF COMPLAINT. LL' i_ [/.A .. DRV RUN: O YES 0 NO REASON FOR DRY RUN AUTHORIZATION FOR DAY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES:(SIGNATURE)X C tip yt • MEDICAL COVERAGE: INDUSTRIAL O YE! .,Z NO NO.OF PATIENTS: ,, a S.S.N a r PRIVATE INS.CO.: BASE RATE: KAISER N: MULTIPLE PTS.BASE RATE BLUE CROSS#:"/ / G/ - < % /1. L.>C TOTAL MILES: %l X kn r j r i� ;_y.� ,r 4 -u MEDICARE N. ` � � E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO M. y. - 0 YES.,O NO NIGHT: (19:00-07:00) '; CCHP/PPHP N: EMERGENCY RUN: MEDT-CAL C CODE 2/3 OTHER: OXYGEN: (PER TANK) P.O.E.STICKER 0 YES NO NEONATAL- (INCUBATOR) DATES BILLED: - r '�" I' STANDBY: (OVER 15 MIN.) �12LeL ,L .Cj-`'i• iw" E.K.G.: (PER EPISODE) n j } NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X ter. '" "u�'� DRUGS: (PER ADMIN.) X NAME: �' ' r'I'r RELATIONSHIPL. E.O.A.: (IF NOT REPLACED) rORAL AIRWAY: (IF NOT REPLACED) CITY: /' STATES ZIP:__ C-COLLAR: (IF NOT REPLACED) i. s,. PHONE:^"•? L'2 WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: '_;; r, ['• ADDRESS: CITY: STATE: 21P: -- ---- f,`:,;•; r;: COMMENTS: TOTAL: �•f-� _132' ; f PATIENT RECEIVED BY: X Pror•idir main Vhite ani Nn1 tory Astute T+:tou +•ary to FX* uMn 4i Li[.q ISIGNATURE) 04-1 "•��i' � U1:11fAN1) • DEMAND N0. 207 L4 =4D vENDOR NO.® on the Treasury or the COUNTY OF CONI RA COSTA Presented By: STATE OF CALIFORNIA DATE 6-18-82 NAME (LAST) , IMPORTANT 46nl NEVTN AVENUE- See Instructions on Reverse Side ADDN[!E CONTRACT # 22-079-8 CITY, $TATE ZIP Coot DATE: 7-1-81 to 6-30-82 For the sum or *****ONF TMISANn SEVEN HIIN11RFn TWENTY FIVE A ?SIT()()***_ DOIiOTi ! .1 -725-25 — As itemized below: UNCOLLECTIBLES DATE DESCRIPTION AMOUNT RECEIVED -- - - ---'-'- ------ --=JUN 21 t _ SEE ATTACHED Emermcv Medical Sen ices PAGES --- ORWARDED 1982 —7 ocr•y�Aedlca'��Pvlecl RECEIVEQ JUL 13 1982 DILLAC AMBULANCE The undersigned under the penalty of perjury states: That the above claim and the items as therein set out are true and correct that no part t.hcreof has been heretofore paid, and that the amount therein is just) due, and that h same is presented within one year after the last item thereof has accrued. / - Signed ./ /• VENDOR N0. - ._ .ter•..cl...-�� - - Received, Accepted, and Expenditure Authorized f Y DEPARTMENT NEAD'O TN at•DEVUTr TU-ff-WJ 1 ACCOUNT r N C PAYMENT M U I TAXADLI AMOUNTTIACT VITY ISPIC FLOSA 017COI/NT FFFM SUM.ro Irv01C[ DAT[ DESCRIPTION FUND oxo. ACCOUNT [NCUMS"arc[ 00. P C PAYMENT AMOUNT 1 AXASLI AMOUNT Tu" OPTION ACTIVITT !. VISCOUNT _ I wr ro. Irrole wr e[ecNlnoN P UMD wa. AeeourT [Ncuruarc[ No is t PAYMENT aEpMyT J , TAAAeL[ AMOUNT TASK OPTIONACTIYIT/ 18P9C rLST DISCOUNT (AIS AYr. 7/77)• • CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I ` ` UNIT � AUTHORIZATION N 0Y. . ,'1,?nd• 0001,CHECK OR FILL/N AMAOMUIE spACEs DATE' /� �'~•! F'' PATIENTS NAME /L L d'1 iP U �/ p p { 7 �--_� 40- . COMPANY N ,ADDRESS 2 �J .� �,�I/�•� cJ LZ A G' AGE._,L—� . .c y�7ur-/� STATE ZIP DOB p Sr,"p M';p t p Vy B p JFp g; •! 1dLt ei#1'j yr� Al DRIVER'S LICENSE N PHONE232 NATURE OF OISPATCI ,__��� 4 TYPE OF TRANSPORT: AMBYLANCfiQ,OTHER O r H INCIDENT LOCATION: "' RESPONSE CODE 'r. REQUESTED BY: TIME_(24 HOUR C OCK) t t� //� ❑ S.O. CALL RECEIVED .' ;)'�/C -1 1pla/✓ / 1 ��_ TO SCENE=��� I r ,ipk A'f't p P.D. , TIME 10.5 + PATIENT DESTINATION: ' FROM SCENE O FIRE S' `TIME 10-97 � w.vNf ^ ..i X./`/ S t; ,:. ❑ VSAP / " TIME t !� MILEAGE: ❑ OTHER TIME 10.7 4P � t I END TIME 1098•��)t a ; `lf DOCTOR �{ � / 'S P..M3/ER START / 9 i TIME 1022t" T *� LNOw CHOSEN: : TOTAL STANDBY TIME, NEAREST p FAMILY ` -Q-TRANSFER .WAIT,TIME i p PATIENT p OIRGCT p OTHER '2 CALL BACK N: ' AMBULANCC C8 I�PANY t '1A PT. MBULATORY? PATIENT TAKEN TO AMBULANCE RESPONSE-ZO r ' ' - e� n �� p YES.Ett Ni i 0 WALKED O GUERNEY�OTHER ` t ' • f+i'GeeJ'..'I * wt1>.>.PATIENT CONDITION: DRIVER T-1 'a 4 P+z` � TECHNICIAN PARAMEDIC ky, ti+{ i Hx: DISPATCHER: CU4 1 C �'c yIEF COMPLAINT: 1Q� /Z - ��wA,-� DRY RUN: p YES 11NO REASON FOR DRY RUN" AUTHORIZATION FOR DRY RUN(EMS USE ONLY PATIENT REFUSED SERVICES:(SIGNATURE)X f ;r� ,MED1COVERAGE: INDUSTRIAL p YES 0 NO NO OF PATIENTS: ? ti t4r PRIVATE INS.CO.: BASE RATE:— KAISER N: MULTIPLE PTS.BASE RATE BLUE CROSS N: TOTAL MILES: /-7i +j+1 X.., MEDICARE N: E.O.B.ATT. ROUND TRIP: 0 YES p NO 0 YES 0 NO NIGHT:(19:00-07:00) i CCHP/PPHP0: EMERGENCY RUN: MEDT-CALM: CODE 2/3- i s t OTHER: OXYGEN: (PER TANK) _ +. i i P.O.E.STICKER O YES ONO NEONATAL' (INCUBATOR) �... �T DATES BILLED: 3Jg�Asg b-/�-�L STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X 3j > , �� :�,�,• DRUGS: (PER ADMIN.) X NAME:- L RELATIONSHIP-,--, %"' E.O.A.:(IF NOT REPLACED) ADDRESS: N "f"'` 'ORAL AIRWAY: (IF NOT REPLACED) CITY: '' STATE ZIP* _ C-COLLAR: (IF NOT REPLACED) zv f jy Y PHONE:'` 3 ' 7 WORK PHONE: DRY RUN: (AUTHORIZED) • EMPLOYER: OCCUPATION: OTHER: gye.r ' ADDRESS: INC I " CITY: STATE ZIP' COMMENTS: _BECEIVEDlak 982— :� _arL::, TOTAL + DUATAMHMWCE- PATIENT RECEIVED BY:X :(516NATURE) pfovidrr Htain White mid link Dopy RatSu-+ pilau copy to OL;uhrn billing , .. OSS ' u - __-' '. ______._. ___. � w• . DENIANU N0. 209 DEMAND VENDOR N0. A • 4 4 D R an the Treasury of the y COUNTY OF C'ON'TRA COSTA 6=18-82 Presented By: STATE OF CALIFORNIA DATE CADILLAC AMBULANCE SERVICE INC. • NAM[ (LAST) 1 (FIRST) IMPORTANT 4601 NEVIN AVENUE See Instructions on Reverse Side ADDRESS RICHMOND. CA 94805 CONTRACT # 22-079-8 CITY, STATE zlr CODE DATE: 7-1-81 to 6-30-82 For the sum of ***ONE THOUSAND NINE HUNDRED FOUR AND 40/100********** Dollars 1,904.40 As itemized below: UNCOLLECTIBLES DATE DESCRIPTION AMOUNT ED EIVED I PAGES JUV, 2 1 19Q2 I _ Emernency Medical Service FnRWARDED (�1 "'244 1982 RECEIVED '1"0enry Afedleel Serviee., J U L 13 1982 C WC AMBULANCE The undersigned under the penalty of perjury states: That the above claim and the items as therein set out are true and correct; that no part thereof has been heretofore paid, and that the amount therein is just u and that the sarAe is presented within one year after the last item thereof has accrued. Signed r W VENDOR NO. Received, Accepted , and Expenditure Authorized �,�� �'' •'•~ �� % y DEPARTMENT MEAD OR CM[{SDE PUTT �� 1 OU M M / C S TM N yMy L1A*L9 AILOWNT T SO OPTIONACTIVITY SPEC. FLIS.1 DISCOUNT 1 1 1 SUM. MO. INVOICE DAT[ DESCRIPTION /URD ON. ACCOUNT [NCUMSRANCE 010. P PATM[NT AMOUNT 1 1 ASASLt AMOUNT TASK DPTgM ACTI VITT t DISC SUM ■O. INVOIC 1 DE SCMI TION FUND/046. ACCOURi CUM AN N0. P/C } PATMENT AMOUNT 1 , 1 TASASLE AMOUNT TASK OITIOM ACTIV ITT SP[C PLSS DISCOUNT . (01S RRv 7/77) ' It F`f CONTRA COSTA COUNTY AMBULANCE f ,: .. •int ''-` PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION M Q 11, + i0.L AViPPROPR/ATE SPACES �CMEC1f R DATE: 1 A n� T PATIENTS NAME-J '�ld�l N �� -� s JR,/M F COMPANY• `�'' } ADDRESS 1D� 17th 5-4 AGE s Y 'CITY I N O STATE` "� '_ZIPT �a' DOB VNATUI O So OM O T;O WO ThY XFF O S9+ �„ .-N.-DRIVER'S LICENSE 0 PHONE E OF DISPATCH ° TYPE OF TRANSPORT: .AMBULANCE OTHER 13 tom• : .. _.` •�,*:{' �,}J t'" } ,T' JCkj��� INCIDENT LOCATION RESPONSE CODE REQUESTED BY. TIME—(24 HOUR CLOCK) TO SCENE- �' O S.O. CALL RECEIVED il �S P •�� Z' ,' ❑ P.D. TIME 10 8 `FC */ / tl: •' L. ;, Y••`^ PATIENT DESTINATION: FROM SCENE ;T. O FIRE TIME 3� Ax 4 i.; Cl PSAP .TIME.10-49 • " ! J mE/C`� Y) 11n MILEAGE., T ER/PVT TIME 10-7 t �.r �Q y ION END TIME 10-98y .. ' S}1 "D DOCTOR QUER START TIME 10.22 ` -r s m ` 7tiOW CHOSEN: I TOTAL STANDBY TIMNEAREST" a FAMILY �' PI"TRANSFER _ WAIT TIME "'; f r' } � 0 PATIENT 0 DIRECT OTHER CLL BACK M: AMBULANCE COMPANY: � s• .. - PT.AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE , r i „..! (a YES NO O WALKED OGUERNEY O OTHER 7 li -.v1tn Ft PATIENT CONDITION: / DRIVER��(�GV� EMT-1A A9.' �t } TECHNICIAN PARAMEDIC ~� Ae xtf h f H. DISPATCHER: - �A t, +j,` CHI F COMPLAINT: 'DRY RUN: O YES PNO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) F •" ' - �` -.PATIENT REFUSED SERVICES:(SIGNATURE)X '�•r •' ••rr r r 2 Pi• �•.:• r� Fn MEDICALCOVEERAG / ^ INDUSTRIAL AYES,O NO NO OFFPATIENrTS: + 't`t•'4'`3}� t S.S.«— � 1 � C'�' �o`�_` ' - '• .}.:� .-i �.r''I r�Y. �..{yii �• 'u1•.• 9 �to d BASE RATE. .; ; c• . PRIVATE INS.QO.:Qp 1c•� /n U5. ea r/�Qr KAISER.#: MULTIPLE PTS.BASE RATE S. •1-�— • •ll� �d BLUE CROSS A: TOTAL MILES: �OM7 X ,t �,8nQQ }F MEDICARE p: E.O.B. ATT. ROUND TRIP: 0 YES � NO yr s O YES 0 NO NIGHT;(19:00-07:00) CCHP/PPRP p: EMERGENCY RUN: w. iZ MEDT-CAL ft, CODE 213'-* .^ a OTHER: OXYGEN: (PER TANK) Tr ' s r P.O.E.STICKER O YES ❑ NO NEONATAL: (INCUBATOR) a., L - STANQBV: (OVER 75 MIN.)BILLED: ��r L E.K.G.} (PER EPISODE) � NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (SER ADMIN.) X "' `"" 8 t•i _ DRUGS: (PER ADMIN.) X , NAME: RELATIONSHIP' E.O.A.:(IF NOT REPLACED) w:ut ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) "! CITY: STATE_ZIP' C-COLLAR: (IF NOT REPLACED)" r • PHONE: WORK PHONE: DRY UN: (AUTHORIZED) EMPLOYER: _aOCCUPATION: " " a y -. ADDRESS: r CITY: Q�C N� STATE: A ZIP — `},`� RECEIVED COMMENTS: -''>"$'• .. _ TOTAL: 9I,D 5 �`• cs ' 3t , CADILLAC AMBULANCE I PATIENT RECEIVED BV: ' (SIGNATURE) ' Avuider rotaia Yhi to rmd 7i'rtk a+py Fotum ItIIw ropy to f.�="ahta biI ng • _ • DEMAND NO. 210 DEMAND VENDOR NO. A 4 4 0 6 0 0 0'3 � on the Treasury of the COUNTY OF CONTRA COSTA STATE OF CALIFORNIA 6-18-82 Presented By: DATE CADILLAC AMBULANCE SERVICE, INC. MAYS (LAST) If IN ST) —� 4601 NEVIN AVENUE IMPORTANT See Instructions on Reverse Side AORICHMOND, CA 94805 CONTRACT # 22-079-8 CITY, STATE lip CODE DATE: 7-1-81 to 6-30-82 1 1 1 I 1 1 For the sum of ***ONE THOUSAND NINE HUNDRED THIRTY FOUR AND 55/100***** Dollars $ 1,934.55 As itemized below: UNCOLLECTIBLES DATE DESCRIPTION AMOUNT SEE ATTACHED PAGES Jui4 2 1 rnergency Medical V'� G�ll tit N d�0� D) """`� h6maotl cnnWARDn ,;Uig 2n 19 2 la �-- � �(1 pC• a� �V�iV� ••a r0�e.,�5• 2 0 jZ Ic:genrY Medical rvicc9 RECEIVED AL 13 1982. The undersigned under the penalty of perjury states: That the above claim and the items as therein set out are true and correct that no part thpreof has been heretofore paid, and that the amount therein is just duel, and that the same is presented within one year after the last item thereof has accrued. Signed VENDOR No. Received, Accepted , and Expenditure Authorized e DEPARTMENT 14EAQ OP CHIEF PEPUTY fUQ1Ia C OU Y M P C ► YMEM ANOUNT �/ � W + 1 oV f tTANAILI ANOWNTOPTION ACTIVITY 11PIC. FLIS-1 016C5UNT SUM. 010. INVOICE DATE DESCRIPTION FUND 0116• ACCOUNT [MCUMSRANCE 110. P/C PAYMENT AMOUNT , 1 .. TAXASLI AMOUNT TASK OPTION ACTIVITY VISCOUNT + , , 1 sum RO. INVOIC 'Di 1T OESCNI TIOIS FYNO M6. ACCOUNT [NCUMENANCE M0. ►/C , PAYMENT AMOUNT' TI■A6l9 AMOUNTAS PTI CT IV ITI DISCOUNT 137- T S 0 ON A EPIC PIES (017 Row 7/77) - . CONTRA COSTA COUNTY AMBULANCE ^ i� ORE-HOSPITAL CARE FORM I UNIT AUTHORIZATION N �w 2 Na so �a •••� CHECK OR FILL INA ATf SPACES DATE: A' \ v PATIENTS NAME �/Q-f /v(J14'V e 1��� ❑ M ¢�TF COMPANY Nft � 1 ADDRESS$ 1-Z L Pf7C/ (nJ AGES' CITY STATE .ZIP= DOB[ L ❑ Sn� M ❑T M.W:i'❑Th ❑.F ❑S' - T4 ; ..+ i- DRIVER'S LICENSE N PHONE 3 Z-V�Lfr e NATURE OF DISPATCH ;fi,•.TYPE OF TRANSPORT: AMBULANCE❑ OTHER❑ - ~ " { f ,1NCID T LOCATION:- RESPONSE CODE REQUESTED BY. TIME—(24 HOUR CL K) +�{ �~ TO SCENE- ❑ S.O. CALL RECEIVED K"iI 1` f/ t (tel `t "� e Z ❑ P.D. TIME 10.8 1 ', 4PATIENT DESTINATION;' -� FROM SCENE- ❑ FIRE TIME 1097 OA + t s`C• r v , w_ LtJ :' ❑ PSAP TIME 10.49 MILEAGE ; "yS'`./ OTHER/PVT, TIME 10.7i END TIME DOCTOR �Q)/J z PMD/ER START` TIME 10.22 IR HOW CHOSEN: 1 TOTAL "- STANDBY TIME, Yt .31 t )��� •❑ NEARESTµ Q FAMILYTRANSFER• -r WAITTIME r `, ❑ PATIENT D DIRECT OTHER � CALL BACK N;. ';'. ;AMBULANCE COMP f .•� �. 6. `I�,;rA PT.AMBULATORY? PATIENT TAKE TO AMBULANCE RESPONSE 20N '. ,YE Nb dJ0` ❑ WALKED GUERNEY O OTHER r i ,PATIENT CONDITION: DRIVER 5'� _ f I• i a r TECHNICIAN 0"� PARAMEDIC Hx. 0 C DISPATCHER: L�►W1cf s t i �i� � CHIEF COMPLAINT: -DRY RUN: 11 YES 6NO REASON FOR DRY RUN = `h AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES:(SIGNATURE)X • D MEDICA COVERAGE: INDUSTRIAL ❑ YES.,❑ NO PATIENTS', . PRIVATE INS.CO.: BASE RATE. f, KAISER N: O/ -3017 MULTIPLE PTS.BASE RATE BLUE CROSS N: :TOTAL MILES: SH. X,; MEDICARE C E.O.B.ATT. ROUND TRIP: ❑ YES ❑ NO.. la ❑ YES ❑ NO NIGHT:(19:00-07:00) EMERGENCY RUN: •� c-CGRP/PPRP N: t' t .MEDI-CAL N: CODE 2/3 OTHER:' -- OXYGEN: (PER TANK) y7 it P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) yQg1� > �1� DATES BILLED: .2-�G`8� �-/Y—S1 '/`�-�? I STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) Y �%4}• NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X ' DRUGS: (PER ADMIN.) X NAME:_//(?,, to2:— �i1//'/ RELATIONSHIP:/ �3 E.O.A.: (IF NOT REPLACED) :r 1ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: STATE_ZIP' C-COLLAR: (IF NOT REPLACED) PHONE: WORK PHONE: DRY RUN: (AUTHORIZED)- 6 EMPLOYER: OCCUPATION: OTHER: ADDRESS: CITY: STATE: 21P �• t �.: COMMENTS: RECEIVED 1111 13-4982 TOTAL: CAnu I AC_9M8UlaKt__ �i PATIENTTil.1,� QJI r,s �''• � _ TIENT RECEIVED D � Y. • 'd' • Provider mWin White and Pink copy . Ret,,ti, Eetiow copy to ENS when bifunq .(SIGNATURE) EMS�1 :- ✓"_', DEMAND NO. 211 / OIiMAND • J VENDOR N . A 'J!±-L2J L6,QX .Q on the Treasury of the COUNTY Of CONTRA COSTA STATE OF CALIFORNIA 6-18-82 Presented By: DATE CADILLAC AMBULANCE SERVICE. INC. NAME (LAST) 1 (P IR ETI IMPORTANT 4601 NEVIN AVENUE See Instructions on Reverse Side ADDA[!S RICHMOND, CA 94805 CONTRACT # 22-079-8 CITY, !TATE !IP coot DATE: 7-1-81 to 6-30-82 1 1 1 1 1 For the sum of ****ONE THOUSAND EIGHT HUNDRED TWENTY AND 85/100******** Dollars $ 1,820.85 As itemized below: UNCOLLECTIBLES DATE DESCRIPTJON AMOUNT RECEIVED + SEE ATTACHED PAGES Emergency Medical Servicer JUN 24 1982 Cmergenry Medical Service^ Nr - .2/0,317 -210407-2io407 i atoi ; a/o3o3 a,vs=.2 : q 1082 . - a�e!34F CAJ The undersigned under the penalty of perjury states: That the above claim and the items as therein sgt out are true and correct; that no part thereof has been heretofore paid, and that the amount therein is jus dup. and that th a e is presented within one year after the last item thereof has accrued. / 1 Signed VENDOR No. Received, Accepted , and Expenditure Authorized ` i DEPARTMENT MEAD OR CMIEF DEPUTY T—UYITI INVOICE DAY 1 09 A C I I PT I ON OU Y M0. P C ► TY M AMOUNT k 5 119671 1 N4L9 AMOUNT $I OPTIONACTIVITY IIPCC /LES. , DISCOUNT 1 1 , 1 lUY. Y0. 1*YOIC! OAT[ DESCRIPTION FUND OAS. ACCOUNT ERCUMSRAYCE 00. P/C PAYMENT AMOUNT 77 7 � 1 •*Aal It AMOUNT TAE* OPTION ACTI III Tt DISCOUNT ' L ! 139 SUIT NO. IIIVOIC T OI!CRI TION FUND ORS. ACCOUNT tNCUMSRANC[ NO. ►/C , PAYMENT AMOUNT 1 1 r ►ANlll[ AYDD*T fU* OPTION ACTIVITY I S-IC Il*7 1 DIlCOYMT CONTRA COSTA ATY :AMBULANCE PRE-HOSPITAL CARE FORM I Ut+rT /// -- AUTHORIZATION N 24 7-' ' CHECK OR FILL INAPPROPRIATE SPACES DATE: 63 j.jr,'j,+" PATIENTS NAME ❑ M F COMPANY N 15 ADDRESS AGE v' �/ r, TQ CITY- STATE 'ZIP_ : DOE; ❑ Sn ❑ M ® T<.' ❑,Th`.❑ F S..,' .p� ! DRIVER'S LICENSE N. ' PHONE __ ATURE OF DISPATCH i tr IK TYPE OF TRANSPORT:,AMBULANCE❑ OTHER❑ I { u INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME (24 HOUR LOCK) TO SCENE- `I ❑ S.p. CALL RECEIVED Q try Si+ �i I r I ❑ P.D. TIME 148 's, t PATI NT DESTINATION:, FR M SCENE�� i ❑ FIRE TIME 1497 " .� � r-'j , + F�) �/ �- 1� . . �`• f I13 T P'. TIME 14d9 " (' kf � MILER �` I HE�./ TIME 147 S` �' +. • c END S 0 TIME 1498 ip} " + ?. DOCTOR ---.] lY)n1 S P /ER START -- � TIME 1422 Al OW CHOSEN "" ' TOTAL j STANDBY TIME ,� ❑ NEAREST ❑ EAMILY TRANSFER ; WAIT TIME tiff ;- ❑ PATIENT :d DIRECT OTHER /D i CALL BACK N: AMBULANCE NY,. ') PT.AMBO TORY?.. PATIENT TAKEN TO AMBULANCE: �" RESPONSE ZONE: Ly^+'t ❑ YES NO. ❑ WALKED �I+ GUERNEY ❑ OTHER--' �K++ r�r I�i1'�PATIENT CONDITION: ; .. DRIVER EMT-1A J. + TECHNICIAN_r Pf) AMEDIC k 4 1 i Yl Ll /�L TLX R - t' HX: ��I.fIFFf'��.lJ��.S• 1� iQfi�st .DISPATCHER: _ t;.••,'' ice. .x,;S;.CH COMPLAINT: �S DRY RUN: ❑ YEd Q NO REASON FOR DRY RUN P Irl 6>`�N _ .r1��Fdd/ / C 'AUTHORIZATICIN F09 DRY RUN(EMS USE ONLYI �jk r g .. PATIENT REFUSED SERVICES: (SIGNATURE)X d MEDICAL COVERAGE:"�"j ,_• INDUSTRIAL❑ YES NO NO.OF PATIENTS: -. .•o•:ra.. esti, ' + k w: S.S.N "'� t PRIVATE INS. BASE RA'-e: KAISER N: SD MULTIPLE PTS. BASE RATE o?Y BLUE CROSS C TOTAL MOLES: �D/r X 1 ' MEDICARE C E.O.B.ATT. ROUND T RIP: ❑ YES Y NO r♦ , Yr �F �A"�S� ❑ YES [1 NO NIGHT: (19.00-07:00) `frp lt CCHP/PPRP EMERGENCY RUN: l " GilFti $ MEDT-CAL N: CODE 2/3 OTHER: OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED: -?-� �-g-� 3-/9-k1 (P -/S�-E� STANDBY: (OVER 15 MIN.) e?.•, „ S. E.K.G.: PER EPISODE) ~ „ • NEAREST RELATIVE/RESPONSIBLE PARTY: ti LV.: (PER ADMIN.) X- �� .k DRUGS: (PER ADMIN.) X NAME: RELATIONSHIP' E.O.A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) rt CITY: STAT E�j: EMD C-COLLAR: (IF NOT REPLACED) • . PHONE: WORK PHO���j�(" DRY RUN: ,(AUTHORIZED) EMPLOYER: _ OCCUPXiICtN:1�2 OTHER: i r _ r. r+ ADDRESS:_ o CITY: CLAMENTS: C � 7 ..f...6 •` 11 TOTAL: Yl Tr�44c V4 7 L� �— PATIENT RECEIVED BY:X �.� + Imwider mtoir, white ,n,d M•ry rovy Fetum Yellck, mru t: !'• ;a>:r. bir?i,:a (SIGNATURE) d5-1 . • - DEMAND NO. 213 VENDOR NO. A IWKIANI) • rfff'-4 D H7, O, 0, 0� on the Trensury of the COUNTY OF CONTRA COSTA 6_18-82 Presented By: STATE OF CALIFORNIA DATE CADILLAC AMBULANCE SERVICE, INC. MAI[ Hurl + InNIITt IMPORTANT 4601 NEVIN AVENUE See Instructions on Reverse Side ADDRESS RICHMOND, CA 94805 CITY, STATE :Ir CODE CONTRACT # 22-079-8 DATE: 7-1-81 to 6-30-82 For the sum of ***ONE THOUSAND FIVE HUNDRED SIX AND 30/100************* Dollars = 1,506.30 r. As itemized below: UNCOLLECTIBLES DATE DESCRIPTION AMOUNT - --- - .-----------------R€CEDED--... ..� - - ---AIN 91_1022 TACHED rmerqpnry Medical Set ices PAG 15 L pnPWARDED--- JUpI Z,5 RECEIVED Emergency Medical Service^ JUL 13 1982 A H-LAC AMBULANCE The undersigned under the penalty of perjury states: That the above claim and the items as therein set out are true and corret that no part thereof has been heretofore paid, and that the amount therein is jus dand that the. am is presented within one year after the last item thereof has accrued. / Signed VENDOR N0. L+�"•' •��,"� Received, Accepted , and Ex Denditure Authorized DEPARTMENT MEAD ON neer DEPUTY !Uhl.Igo ur ND.IF/Cl I PAYMENT AMOU Illy Wov/ 1 1 1 ..r t TANA l9 Aso-illy TAWit ■ C VITT IIIPIC FLIISA DISCOUNT I + SUN. N0. INVOICE DATE DESCRIPTION PUNO OAS. ACCOUNT Er Cur SNANCE 40. ►/C I PAYMENT AMOUNT , , At AIL AMOUNT TASK OFTgM ACTIVITY DISCOUNT I I sur 00. INVOICE DAT11 OESCRI TION FUND OAS. ACCOUNT ENCUMBRANCE 100. P FAYME Y' UNT I TA■AIN S AMOUNT TR O/TION ACTIV ITT S►EC FLII! SDISCOUNT r + toll Rw. T/?T) CONTRA COSTA COUNTY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATIONM/S/O��`J • `' �`�,';' , ;'�^'!.' CHECK OR FILL IN APPRO7R/ATE SPACES DATE: - A .� 1 `Irt PATIENTS NAME I I0ay1`r M ❑ ` COMPANY M ' y ? ADDRE SbQ AGE I S l ' CITY STATE ZIP DOB D Sn M D T. ❑W ❑_,Thr❑ FAD$ + DRIVER!SLICEN h 0 PHONE(L�JL6��a1�cNATURE OF DISPA CH TYPE OF TRANSPORT..AMBULANCE OTHER❑ ryl`ir, INCIDENT LOCATION: M ` RESPONSE CODE: REQUESTED BY: TIME (24°HOUR CLQCK)`r ? � TO.SCENE- /� ❑ S.O. CALL RECEIVED :.. , r ❑ P.D. TIME 10-6 T- y �r y YTfi �e PATIENT DEST ATION: FROM SCENES 13 FIRE TIME 10-97 /li .❑ PSAP ' . . { ..TIME 10-49 7z1S r K +S /y ✓r l ► 10-7 Lt } :MILEAG�: OTHER/PVT TIME ''UU blt'f s. ; TIME 10-98V' s 1:im r t'pls ,Y DOCTOR PMD/ER _ START i TIME 10.22 IpW.CHOSEN: TOTAL . STANDBY TIME _ _r �$ yX' pi j; ""'va�'D NEAREST _ FAMILY D TRANSFER �. WAIT TIME 1�f, 'f'�.+ ❑ PATIENT "kDIRGCT ❑ OTHER CALL BACK C AMB C0MP(gNY: } •J D.PYAMBULATORY? PATIENT TAKEN TO AMBULANCE: . RESPONSE ZONTES D WALKED D GUERNEY W OTHERUA :C1 `' (u*r :+ IMM AfIENTCONDITION: F o_ . DRIVER EMT 1A � 'sri-.• TECHNICI N MEDICS �s3 Hx, ')' ' 'DISPATCHER' K CHIEF COMPLAINT: DRY RUN: ❑ YES XNO REASON FOR DRY RUN n(`L.n - AUTHORIZATION FOR DRY RUN(EMS USE ONLY) ,f t +`jPATIENT REFUSED SERVICES:(SIGNATURE)% �g MEDICAL COVERAGE: INDUSTRIAL NO❑ NO . NO.OF PATIENTS: :• t y""', �'� yr vil S.S.r ,., Lli L.LI/:NM ICU fppef1'/l( R,�f pal PRIVATE INS.CO.: BASE RATE .. AN, ri+oAN (,QL�• _t�,•���y.�]p �.t. KAISER#: MULTIPLE PTS.BASE RATE BLUE CROSS 0: TOTAL MILES: '- j X 1 )Sz• rr Y kr MEDICARE M E.O.B. ATT. ;ROUND TRIP: `O YES D NO y D YES ❑ NO NIGHT:(19:00-07.'00) 01 �CCHP/PPHPp _ " EMERGENCY RUN - � ���5 � ••' �l�y��y "•� y ri MEDT-CAL M: - CODE 2/3 ( "It ,'" F e. OTHER: OXYGEN: (PER TANK) i? i P.O.E. STICKER ❑ YES ❑ NONEONATAL: (INCUBATOR) DATES BILLED: J� 23-L21., -34 1 Q Ql• STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) F` NEAREST RELATIVE/RESPONSIBLE PARTY: ` I.V.: (PER ADMIN.) X "" ' ,, / DRUGS: (PER ADMIN.) Xi''• . NAME' ,) jJbIldGATIONSHIP M E.O.A.: (IF NOT REPLACED) 'ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: / 1 I STATE ZI d C-COLLAR: (IF NOT REPLACED)' - t" i + 1 • PHONE: ' WORK PHONE: DRY RUN: (AUTHORIZED) ''' EMPLOYER: OCCUPATION: OTHER: '! ADDRESS: CITY: STATE- ZIP: " •"'i i' COMMENTS: " ' ''' • . ECEIVE6 111982 TOTAL: O, ,. ­-CADILLAC-AMBULANCEPATIENT RECEIVED BYATURE . Pivvider retain White mid Pink mpi, . R•trm Y011010 mpy to ivr i$.-,: Filling ,(i ENS-1 "' 67 CONTRA COSTA COUNTY AMBULANCE n/ '`�} D tC [J PRE-HOSPITAL CARE FORM 1. UNIT AUTHORIZATION N I•.��'•': CHECK OR FILL IN APPROPRIATE SPACES - DATE ..� V•,t. _AILLa - PATIENTS NAME r 1Ok M p F COMPANY N S AGE 101 s 1 rA CITY STATE �ZIP,q u 5 _ DOB IKSn ,� M O.T� O W O.Th F❑ FM_O s';: 1 ' :,+, 'r,':?•`,�„�1 DRIVER'S LICENSE M PHONE6 3� NATURE OF DISPATCH TYPE OF TRANSPORT AMBULANCE OTHER INCIDEN4%LOCATION: ` ' RESPONSE CODE REQUESTED BY: TIME—(24. OUR C CK) TO SCENE- ❑ S.O. CALL RECEIVED ' a'�� f X11 •.h7'' (J('_�J��i �[l�`aIlL1 /� 7!n/J� 1 .. ❑.P.D. TIME 10-9 T'!..•.'�'� r, PATIENT DESTINATION: FROM SCENE- `•a• ❑ FIRE TIME 10-97 : 1T I,. O PSAP '+ ''TIME.10-49 x�TtT`LZ: •5P, MILEAGE: OTHER/PVT '+ TIME X0-7 + 1 �/ END TIME 10-98. DOCTOR PMD/ER 1 START '' TIME 10-22 t� OW CHOSEN:, TOTAL F STANDBY TIME a it I O NEAREST' EAMILY ❑ TRANSFER WAIT TIME x -+� S-A t t O PATIENT DIRfiCT 13 OTHER �� r CALL BACK N: AMBM E OMP/�NY: IPT.'AMBULATORW­.-. PATIENT TAKEN TO AMBULANCE: RESPIONSE ZON 7a I r ES�'bG NO ' ❑ WALKED ❑ GUERNEY �OTHER 1L.1(��i�' f '1 o PATIENT CONDITION: DRIVER MT-1A TECHNICIAN L� PARAMEDIC r W.I.. HK: } DISPATCHER:' _ ,V CHIEF COMP NT:ANT: PRY RUN: O YES W NO REASON fOR DRY RUN ` 'AUTHORIZATION FOR DRY RUN(EMS USE ONLY) i� .�%v:� PATIENT REFUSE SERVICES:(SIGNATURE)X � ;•��1 1 f i R•. MEDICAL COVERAGE:”' INDUSTRIAL O YES O NO NO.O�ATIENTS: ,t•s.s.« PRIVATE INS.CO.: I C t 14 BASE RA ��(j (D ;. v ii 2F k3 : KAISER N: MULTIPLE PTS.BASE RATE .' BLUE CROSS N' _ :TOTAL MILES: j X _ 7- MEDICARE - _ }! MEDICARE N: E.O.B:ATT. +ROUND TRIP: .O YES ' ❑ NO JL .` ❑ YES ❑ NO KNIGHT:(19.00-07:00) �'` ? 'i ( •� L a '. # is :,CCHP/PPHPp[r 1•: - �EMERGENCYRUN t / c71f .i., � � E;; MEDI-CAL N: .. CODE 2/3 Ir , a s o OTHER: OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES ❑ NO •� NEONATAL: (INCUBATOR) _ DATES BILLED: Z3-RST-19� 4-/'�'rl STANDBY: (OVER IS MIN.) >; E.K.G.: (PER EPISODE) yy �. f, NEAREST RELATIVE/RESPONSIBLE PARTY:'' I.V.: (PER ADMIN.) X i DRUGS: (PER ADMIN.) X NAME 1 OELATIONSHIP: E.O.A.:(IF NOT REPLACED) " " °Y' ' 4' �: ... + ' ADDR S: 11 '( ORAL AIRWAY: (IF NOT REPLACED) 't-'!:` :':'•'� CITY: STAT ZIPL -COLLAR: (IF NOT REPLACED)' _ _...,.\ s.. PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) .; ~ EMPLOYER: OCCUPATION: OTHER: ADDRESS: _. CITY: STATE: ZIP• RECEIVED COMMENTS: IU6 3 198 TOTAL: 1312,(o d r_ADILLAG AMBULANCE— A.? PATIENT RECEIVED BY..x �SIGNATUR Provider Hain Vhi to smAP:'ai copy - Retun'T�S1au ropy to f'.'.: ,+M.n hi llinp I EMS-1 � CONTRA COSTA COUNTY AMBULANCE 1\nQ .Con: = PRE-HOSPITAL CARE FORM I UNIT / % AUTHORIZATION N 11)(71 Di+�'t CHECK ON RLL IN APPROPRIATE SPACES DATE;\L/J(. �L_u�/� , ••• { PATIENTS NAME�� rCLc Fs� � L (��[��Clln- M,.O F COMPANYN ADDRE S AGE — •d1 Vhn CITY STATENI I :,,:ZIP (.r DOB} 1L *Sn OM O T-AO W 0;71}..0 F, S P C� t. Vit; //DRIVER'S LICENSE N PHONE 1Q`1/' NATURE OF DISPAtCH Jf t TYPE OFTRANSPORT:I AMBULANCE OTHER O f- •�..• �: '••,,, ,���I a INCIDENT LOCATION: RESPONSE CODE. ((�� REQUESTED BY: TIME—(24 HOUR C�QCK) e TO SCENE- r' O S.O. CALL RECEIVED s ,^k P P.D. TIME 10-8 l c,":37 i Viµ' PATIENT-DESTINATION: FROM SCENE O FIRE_� TIME 10-97 ihaa c " ti a' ' r O PSAP :3� ..TIME 10.49 'r))1, ' . t R k't MILEAGE: i OTHER/PVT TIME 10-7 y p• END 1 t r TIME1098��: (I . ` A Is ;� DOCTOR- + PMD STAR- "' TIME 10.22 ';,Hpw CHOSEN: j TOTAL _�_ STANDBY TIMI:_' NEAREST .FAMILY O TRANSFER ! WAIT TIME � ' O r" PATIENT . 1kraCT O OTHER / 'CALL BACK N: AMBU� COMPANY. , t til N F.. •.. w _ : ."' ._.FOYES tt BULATORY?: .. PATIENT TAKEN TO AMBULANCE: "' RESPONSE ZONE ' O O WALKED O GUERNEY OTHER (, h F. I r l'(Q.(- ( ' Lk O PATWNT CONDITION: I DgIVER t, MT-tA TECHNICIAN PARAMEDIC__t_ .S(4 Hx: DISPATCHER: - �,+ to HIEF COMPLAINT: lit on I yl, RUN: O YES [ NO REASON FOR DRY RUN d�}� + /' r AUTHORIZATION FOA DRY RU[N(fMS-VSE ddL`Y)r �`4;2 h . •.PA IENT REFUSED SERVICES: (SIGNATOR )X } ,( ' • a MEDICAL COVERAGE: "" INDUSTRIAL O YES O NO NO.OFPATIENTS: ' t S.S. PRIVATE INS.CO.: BASE RATE. (11/1 o . (6L A-f . KAISER N: •MULTIPLE PTS.BASE RAT BLUE CROSS N: TOTAL MILES: �• X, Q_ . MEDICARE N: E.O.B,ATT. 'ROUND TRIP: O YES O NO O YES ONO NIGHT:(119:00-07:00) a 1 . I CCHP/PPRP N:' EMERGENCY RUN: •- + MEDT-CALM: _ CODE 2/3 1`�7?- . OTHER: OXYGEN: (PER TANK) r.c T i �....�.... } . ' P.O.E. STICKER O YES O NO ! NEONATAL: (INCUBATOR) DATES BILL ED' _x-3-1 •4-/9-&-� `-^L-s1 � STANDBY: (OVER 15 MIN.).;; '�` ' �1L[�L• y '� , '���' a � E.K.G.: (PER EPISODE) - ..'_I•/'i, >t` 4�': NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X / DRUGS: (PER ADMIN.) X NAME �2�l�ATIONSHIP E.O.A.:(IF NOT REPLACED) I `, f ADD R cc L 114111 4 ORAL AIRWAY: (IF NOT REPLACED) CITYI STATE ZIP• C-COLLAR: (IF NOT REPLACED) + . PHONE:Li 4� "1 A�� WORK PHONE: DRY RUN: '(AUTHORIZED) 'tT' EMPLOYER: OCCUPATION: OTHER: Zk_ ADDRESS: CITY: STATE' ZIP' _ RECEIVED COMMENTS: -� JUL 13 1982 ---- TOTAL: D V __CADILLAC AMe 1MCI^ PATIENT RECEIVED BY:X Fnrofder retain Vhi Le and/9'nk rnpi. Return 1e12ow copy to !!f" :•kr•, Fill w t81(�'NAT WS-} CONTRA COSTA COUNTY AMBULANCE • / 'l 'PRE-HOSPITAL CARE FORM I UNIT / AUTHORIZATION N - GIECk OR llLl IN APPROPRIATE SPACES DATE: PATIENT'S NAME _ r �!•� 1`'S��-:'� Lam-�) J��� ❑ M lEkF COMPANY N ADDRESS I) t'/lZ� AGE CITY- r� {- STATE�'V ZIP L DOB�� 1- u�� Sn M ❑ T ❑ W ❑ Th ❑ f �+ ` _ ; DRIVER'S LICENSE N PHONEy, - 3�c� (PJATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCEU OTHER❑ INCIDENT LOCATION: RESPONSE C E: REQUESTED BY: TIME-(24 HOUR C QCK)� TO SCENE- ❑ S.O. CALL RECEIVED ❑ P.D. TIME 10-8 PATIENT DESTINATION: FROM SCENE ❑ FIRE TIME 10.97 �Y 3 t ❑ PSAP TIME 10.49 ( L�• MILEAGE: p OTHER/PVT TIME 10.7 7' / C1 END TIME 10-98 / DOCTOR -SLE PMD/ R•! STAR ,�, - - ' " j' TIME 10-22 HOW CHOSEN: TOTAL STANDBY TIME t ❑ NEAREST ❑ FAMILY TRANSFER WAIT TIME s ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK N: AMBULAteEfSOpAPANY: PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE_ ❑ YES"O..NO ❑ WALKED O G'UERNEY ❑ OTHER y,:. PATIENT CONDITION: DRIVER_ -\T -4f75 TECHNICIAN - PARAMEDIC A. Hx: DISPATCHER: CHIEF COMPLAINT: ( �1 r\ �•.�' > I DRY RUN: ❑ YES ❑ NO REASON FOR DRY RUN • `. N AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REF SED SERVICES: (SIGNATURE)X_ MEDICAL COVERAPE: INDUSTRIAL ❑ YES.'d,-NO NO. OF PATIENTS:-_ �.5.N �l PRIVATE INS.CO.!` ' BASE RATE: KAISER N: - MULTIPLE PTS.BASE RATE - a�C F,= •_ BLUE CROSS 4: _--__-_.-_ TOTAL MILES: X MEDICARE N:__- E.O.B.ATT. ROUND TRIP: ❑ YES ❑ NO Q ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP N: EMERGENCY RUN: L.: ati MEDI-CAL N: ) CODE 2/3 r.• >1 f/r • OTHER: -. OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED:-�'-2_ .�.L•.�_ �-L`.B.eR. � �Zl_ STANDBY: (OVER 19 MIN.) E K G.: (PER EPISOCE) NEAREST RELATIVE-/RESPONSIBLE PARTY: I V: (PER ADMIN.) -_._____-.__--.X •. ,/�. 7S / ,DRUGS: (PER ADMIN.)._ X 11 1 j -� �t I-- 1 I `11(. NAME: -L-" _-:i____L.._�-'._ RELATIONSHiI'. .-.. __. E.O.A.: (IF NOT REPLACED) � .• ADDRESS:, - _-..____ ORAL AIRWAY. (IF NOT REPLACED) CITY:"_�—_ STATE-____ ZIP:----------- C-COLLAR: (IF NOT REPLACED) PHONE: `1 ( - L >>, DRY RUN' 1AUTHORIZED) EMPLOYER: - OCCUPATION:._---_-__._- OTHER: ADDRESS:- - ------ ---- --- - CITY:- ------ STATE:_.-."_.ZIP--------- ......... ----- , - RECEIVED -z145 TOTALJ_2,.460----- - ----- - JUL_ 13 1982_ PATIENT RECEIVED BY: X l , .. .:.::.... .... .:. :%CADILLAC.AMBILILANCE ;.. Ic,RNAT11RE1 C I CONTRA COSTA COUNTY AMBULANCE 'PRE-HOSPITAL CARE FORM i '.. UNIT AUTHORIZATION N TI CHECK CHECK ON FILL IN APPAOPRUTE SPACES DATE:-V PATIENTS NAME Q M .F ) COMPANY N-abj ` POD ESSAG�f �, ,•', . *., t > �� !` CITY STATE 7 'ZIP. DO, ❑ M O T' 0.W ❑Th �❑ p�❑S ` ,{ DRIVER'S LICENSE N -PHONE�� �'>MATURE OF DISPATCH V :TYPE OFTRANSPORT. AMBULANC THERO { , INCIDENT.LOCATION: RESPONSE CODE REQUESTED BY: t. TIME--w(24 HOUR R M�L (L` • I\ 1r� ., 70 SCENE ❑ S.O. CALL RECEIVED ' OJ J `"J t. oti ❑P.D. TIME.108 0 =1 i' PATIENT DESTINATION: i FROM SCENE 9 r.. ❑ FIRE TIME 10-97 ��rr }iry`• .,'k. 1tf d-*!'�L ❑ PSAP .;-:y� TIME 10 MIIEA E..0 ri ER/P ' TIME 10 T + TIME 10-9 DOCTOR ° L III TIME 10$2't: TOTAL Z OW CHOSEN ❑ NEAREST. ❑ FAMILY�?RANSFER WAIT TIME j ' ❑ PATIENT ❑ DIRECT O OTHER CALL BACK C. AMBULANCE N PT.AMBU ORY? - PATIENT T EN AMBULANCE: "•"`' RESPONSE ZONEf fill- k moi; ❑.YE SNO ❑ WALKE UERNEV 13 OTHER PATIENT CONDITION: S .+r. ' 'DRIVER TECHNICIAN 1 c PARAMEDIC e "e Hx DISPATCHER: ' CHI F COMP AIyT` t��s PRY RUN: ❑ YES ❑ NO REASON FOR DRY RUN ' A .s� f 4` 1 ►_t M AUTHORIZA IN FOR:DRY RUN(EMS USE ONL ` •;.p� PATIENT REFUSED SERVICES:(SIGNATURE)X ,MEDICAL COVERAGE:­ ) INDUSTRIAL LS YE NO.OF PATIE(JTS( V BASE RATE. I I t A1_ KAISER N: - MULTIPLE PTS.BASE.RATE BLUE CROSS N; TOTAL MILES: �n X MEDICARE N: �E.O.Q ATT. 01ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT:(19:00 07:00) �., ,S.,a ; i b<�.;• . CCHP/PPRP N:'' 'IEMERGENCY RUN: ! it t cX 7o i;• rk 'J 1 A MEDT-CALM: 1 �CODE 2/3 : a V. OTHER: i OXYGEN: (PER TANK) Y. 71F1e`A r : P.O.E. STICKER ❑ YES ❑ NO - NEONATAL: (INCUBATOR) + `2 DATES BILLED:.'.2­2-3-12- . 4_/44.21 to IV-4J„J STANDBY: .(OVER 15 MIN.) E.K.G.: (PER EPISODE) °•�j--'T7� +3 { _` b/,, _^NEAREST RELATIVE/RESPONSIBLE PARTY: .. I.V.. (PER ADMIN.) X • {)� I C �n� R (PER ADMIN.) X .•...1;` NAME: li l _ ....- ::,;�;t•.'.� ,r�•!�; �! � RELATIONSHIPS �F NOT REPLACED) ' ' •yam i AD DRE ORAL AIRWAY: (IF NOT REPLACED) +•'� 'r' (• -CITY: STAT ZIP C-COLLAR: (IF NOT REPLACED) 'I "• • PHONE: ORK PHONE: DRY RUN: (AUTHORIZED) L4 Li W' EMPLOYER: OCCUPATION' OTHER: ADDRESS: Lim CITY: STATE' ZIP COMMENTS. IIL _ RECEIVED- ' z PATIENT RECEIVED BY;X :': ` I -_— (SIGNATUE) 'A•�uib� resi Q1DLAf ' 1MBUUNCx ' • DEMAND NO. 219 .; �.. • 111:AIAND Ca a o f ryE-�— , �° ❑ on the Treasury of the ('UUN IY 01: ('ONTRA CUS'I % Presented By: S'rA'1'E UP CALIFORNIA DATE 6-18-82 CADILLAC AMBULANCE SERVICE, INC. NAME (I.AITI Is IN IT IMPORTANT See 4601 NEVIN AVENUE Instructions on Reverse Side ADDRESS RICHMOND CA 94805 CONTRACT # 22-079-8 CITY, STATE lip CODE DATE: 7-1-81 to 6-30-82 l 1 1 1 I 1 I 1 . 1 For the sum of __ ******FOUR HUNDRED SIXTY AND 00/100****************** - 460.00 Dollars As itemized below: DRY RUNS DATE DESCRIPTION ANOUNT SEE ATTACHED JUW 2 0 9. PAG CTv me S ai Ica rAb —W�''�f - ----- - - -- -- — — -- il2/. _ RECEIVE JUN 2 3 14? Emergency Medical S rvices R€GEIVED- - - - - J U I -198 ADIL CE The undersigned under the penalty of perjury states: That the above claim and the items as therein set out are true and correct; that no part (hereof has been heretofore paid, and that the amount therein is jusplug "and that tha_same is presented within one year after the last item thereof has accrued, v jl�� / ���1 Signed l /•-Tl _ �•-ter, ) VENDOR N0. 1 / ! ° Received, Accepted , and Expenditure Authorized ! �'• �Ot;P AR RTY1pT ISLAD:OCCIII[P DEPUTY" V ACCOV 9MCUMPRANCE M CPAYMENT AMOU , 1. TAXA§Lg AHW* IS OPTIONACTIVITY IIPKC FL43.1 DISCOUNT AUM. Ne. INVOICE (ATE 01ICRIPTIO■ PUNe OM. ACCOUNT INCUMBRANCE 40. 0 PAYMENT AMOUNT 1 7ARABLIK •MOUNT TARE WTgN ICTt VITT OIICOUNT rM � 1 1VM NO. INvOiCt CAT 01/CRITION FUND/Opt. ACCOUNT ENCUMBRANCE N0.JP/CI PATMENT�A �T 'fI— t 1 TARAIl1 AMOUNT TAU I OPTION ACTIVITY IIPCC r693DISCOUNT 1 CONTRA COSTA COY AMBULANCE PRE-HOSPITAL CARE FORM I UNIT © AUTHORIZATION 0�+ CNECI(OR llLl INAPPROPRIAtE SPICEDATE: !7 � (� ❑ M ❑ F COMPANY If ' PATIENT'S NAME_ f ADDRESS AGE r' - 1 r i• CITY_ STATE ZIP DOB 1n ❑ M ;❑T ❑"W ❑TT' ❑ F ❑ S %,i» DRIVER'S LICENSE 4 ._ PHONE NATURE OF DISPATC I�L�/1–�iT"C� •d.;.. I y+ i V ; TYPE OF TRANSPORT: AMBULANCE❑ OTHER y w _ INCIDENT LOCATION. RESPONSE CODE REOUESTED BY: TIME, (24 HOUR C O K) r . TO SCENE- ❑ S.O. CALL RECEIVED.__L[r �1 �ty . ❑ P.D. TIME tae T S Ile y J PATIENT DESTINATION: FROM SCENE ❑ FIRE TIME 1497 TT �hs': ` +;'o- n ❑ PSAP TIME 1x49 i. N r�.. .. - MILEAGE- Ai x•� Ey r �.OJHER/ TIME 1a7 END TIME ta9e A`yF.DOCTOR PMD/ER START TIME 10-22 LFyf+ �W;42, HOW CHOSEN STANDBY TIME. ❑ NEAREST ❑FAMILY ❑ TRANSFER TOTAL WAIT TIME ❑ PATIENT.. ❑ DIRECT ❑ OTHER CALL BACK p: AMBULANCE C M Y: AL ri ','• T PT. AMBUTATORY7 PATIENT TAKEN TO AMBULANCE `T r ( '', \ "•' RESPONSE ZONE ❑ VES ❑ NO ❑ WALKED ❑ GUERNEY ❑ OTHER" PATIENT CONDITION: DRIVER `� h�"' EMT-tA �w�+, TECHNICIAN LSt�� PARAMEDIC r rf t14+ Hz. s DISPATCHER: r' 1 ❑ CHIEF COMPLAINT: � DRY PI IN:�S NO REASON FOR DRY RUN +y` ( AUTHORIZATION FOR DRY RUN(EMS USE ONLY) r "� PATIENT REFUSED SERVICES: (SIGNATURE)X �' ' •MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO OF PATIENTS r. �cti t -. V• } PRIVATE INCO.: BASE RATE. k? sft r ' KAISER a: MULTIPLE PTS.BASE RATE ti BLUE CROSS TOTAL MILES: X � ! MEDICARE q: E.O.B. ATT. ROUND TRIP. ❑ YES ❑ NO ^ ❑ YES ❑ NO. NIGHT: (19:00-07:00) ~ CCHP/PPHP a; EMERGENCY RUN {• t 4 1 hh 1i r ti A`r .MEDI-CAL p: CODE 2/3 OTHER' OXYGEN: (PER TANK) ,•:.+. , �n i' ,#. P.O.E. STICKER ❑ NO NEONATAL: (INCUBATOR) r "+ f. DATES BILLED: STANDBY- (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVEiRESP NSIBLE PARTY: I.V: (PER ADMIN.) X. r.n. DRUGS: (PER ADMIN,) X NAME: RELATIONSHIP: E.0 A.: (IF NOT REPLACED) ,y ' ADDRESS:_ _ ORAL AIRWAY: (IF NOT REPLACED) CITY:_ _. ._ STATE C-COLLAR: (IF NOT REPLACED) PHONE: _ WO PHONE:-- DRY RUN: AUTHORIZED - ( ) EMPLOYER: . — O .UPATION:. OTHER: .'.'"-'e'y+' ADDRESS: CITY:. _...._ .__._ .. ST TE:—_IIP:—._ Lrt + • -,. RECEIVED 1 );( COMMENTS:-. ------ - ..CAD{LLAC AMBULANCE.-_-_. ...._ ! . ,- ] - PATIENT RECEIVED BY: (SIGNATURE) . --4—. .c:1oc rnj'% b f-'(' +EYc-j•'. . _i V EV E NI)I:AIAND • DEMAND NO. 221 4 4 D un the Trcasury of the COUNTY ON CONTRA COSTA STATE OF CALIFORNIA 6-16-82 r GATE Presented By: CADILLAC AMBULANCE SERVICE, INC. MAY[ (Mer) avert IMPRTANT 4601 NEVIN AVENUE See Instructions on Reverse Side ADDRESS RICHMOND, CA 94805 CONTRACT N 22-079-8 CITY, [TATE r11 CODE DATE: 7-1-81 to 6-30-82 For the sum of ******FIVE HUNDRED TWENTY AND 90/100******************* Dollars t 520.90 As itemized below: DRY RUNS DATE DESCRIPTION AMOUNT - ,Jury 2 8.1982_ S CHED Cmorgenry Modica!iervi - PAGES�)o di -__ -- ' -----'-= ---- - -- -----� t'-23198 -- -- --- — RECEIVED—_E 1m JUL 13 1982 CADILLAC AMBULANCE The undersigned under the penalty of perjury states: That the above claim and the items as therein set out are true and correct; that no part thereof has been heretofore paid, and that the amount therein is jus 1 ueyand that the same is presented within one year after the last item thereof has accrued. Signed VEN DOR I+e. Received, Accepted , and Expenditure Authorized «:*�' �`� c"t'•� �' —Qj PANTII_[MT M[ 9!1, "XUL<k TT U ACCOU l 2fb C Y N N I C I TY M •YOU ' .;..: l 1 ACTIVITY VISCOUNT 1 A ELIC FUe. 1 1 1 dull. ■0. INVOICE OAT[ D[ICRI►TION FUND One. ACCOUNT ENCUMBRANCE NO. 0 IAT Y[NT AMOUNT i ANAII AMOUNT tAe[ OPTION ACTIVITY VISCOUNT 1 1 1 1 TUY N0. IN Ct PAT91 018CRITTION FUND/044. ACCOUNT 1ICCUMIRANCE 010. P C PAYMENT AMOUNT 149 ' TANAIIE AMOUNTTAeI OITIOM ACTIVITY V[C nle VISCOUNT 1 I 1 (0 15 Rd. '/r T) 5.: VIE CONTRA COSTA COLIN AMBULANCE PRE-HOSPITAL CARE FM I UNIT � AUTHORATION 4 IQ CHECK OR FILL INAPPROPRIATE SPACES GATE: PATIENTS NAME.T1h A LmlL"r�:1 %k4E.2_ Ltilu.I 1 O / ❑ M ❑ F COMPANY$ p� ADDRESS AGE CITYi STATE ZIP DOB ❑ M ❑ T ❑ W ❑Th ❑ F ❑ S i :3,' DRIVER'S LICENSE$ PHONE NATURE OF DISPATCH" � t�r -�QNJf'rj +'Ika >� � 1 TYPE OF TRANSPORT: AMBULANCE FrOTHER❑ lF�;.L. INCIDENT LOCATION: ' . RESPONSE CODE REQUESTED BY: TIME— (24 HOUR CLO K), }' en TO SCENE- ' ❑ S.O. CALL RECEIVED q ;Y ( j TAk- ❑ P-D. TIME 10-8 _!L + " PATIENT DESTINATION: FROM SCENE: ❑ FIRE TIME 10.97 1g I ' 1 ❑� PAP TIME 10 49 Y- -��`� MILEAGE: V OTHE /PVT TIME 10-7 f END TIME 10.98 �^ � DOCTOR PMD/ER START _ TIME 10-22 ''HOW CHOSEN:' . TOTAY STANDBY TIME".-, '•❑ NEAREST ❑ FAMILY ❑ TRANSFER ' WAIT TIME'' C i 13 PATIENT ' ❑ DIRECT OTHER (� CALL BACK$: AMBULANCE COQ PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE o §N ❑ YES ❑ NO ❑ WAOED ❑ GUERNEY ❑ OTHER PATIENT,CONDITION: DRIVER u— ,2 EMT-lA a TECHNICIANPARAMEDIC ✓�' f L1`J� � CHIEF COMPLAINTn: ILS�07 ��_ -`X: DISPATP DRY R N:E YES ❑ NO REASON FOR DFI ' RUN �7101�, Crt �d Yk,4 V. A \A k�t�Lt �_�UTH FOR DRY RUN(EMS USE ONLY) � �y�k• h PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO.OF PATIENTS: Y rc'h f% S.S. k PRIVATE INS. CO.: BASE RATE: tt) + ': KAISER k: MULTIPLE PTS.BASE RATE BLUE CROSS$: TOTAL MILES: X c • t' , , 3 MEDICARE$: E.O.B.ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) ;yP CCHPJPPHP It: EMERGENCY RUN: 'ty hX,,.$EDI-CAL$: R .. CODE2/3 vdC `�Fct c ,3`F r^:;icy OTHER: OXYGEN: (PER TANK) 777 " z P.O.E. STICKER ❑ YES NO NEONATAL: (INCUBATOR) .. ., DATES BILLED: STANDBY: (OVER 15 MIN.) 4`a ,.a�}E?`+ . E.K.G.: (PER EPISODE) \\ k NEAREST RELATIVE'RESPONSt\LE PARTY: I V.; (PER ADMIN.) X DRUGS: (PER ADMIN.) X '`,' NAME: RELATIONSHIP: E.O.A.: (IF NOT REPLACED) 7. ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) ...,4. , CITY: _ TATE ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: WORK NONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ADDRESS: SMEWED— CITY: E QEDCITY: COMMENTS: _— CADILLAC AM ULANCF TOTAL:—' � 6l.SO _ PATIENT RECEIVED BY: X ' h—eider mta:n ✓kite .,nd 7•int; ,-,.py petym•YtlZew+ ropy to E9f' :•hsn Ciilicp (SIGNATURE) Ot5-1 DEMAND NO. 243 ' ,vrrrnoa rIo A/r, •(at rile file I t ('t It IN'I Y OF Cl),%�' IIt % ('OSI ,% i'resentcd Py s'IA11: 01 1 11111ItN1A DATE 7-8-82 4{ CA_ DILLAc AhlLU Nc[ SLRVICLINC. _ NAME ILA,tl uuerl 1Nf1'011"fANI- 4601 NEVIN AVE14UE _ Sve lustructinns nn Reverse side x -RICHMOND, CA 94805 CONTRACT # 22-079-8 CITY, STAT[ zip Cool DATE: 7-1-81 to 6-30-82 i kl: 1{ •'1 Lam__1,�-1 1 1� ,•�� " For M. ,:.Im Of _**.*.* '.*.***Ot1E HUNDREDTHIRTYFOUR AND 40/100*********** Doltors 134.40 + " As itemized below" RETURN OF EQUIPMENT AND PERSONNEL DATE DESCRIPT{ON AMOUNT i SEE ATTACHED 1 4, PAGES Fms.,ly�n.y Cledical Servi:es -- . - - - - - — -------- -- ...--------" CAD]LIAC-An-'1IrULAKE - The undt'r�zu:i •d undrr oi— pruallc nl perjor.v stairs': That thI' above claim :uni the ittmis as therein set out are true and correct; that no P.uI Illolenl Ila,; bs•I a 111,11,110,111, paid, and Ilial the amount therczin is just'v diff', and that�thersame is presented within one \Mar after flit! 1w;t Ileal fht'I+`r-1 liaq necniod. jv — venooa Nc Rece,:ad, Accepted , and E•iiendifure Authorized j oio.itT HE All ON CHIEF DEPUTY IuYTd' v T - 6[TrI1iT1 M761 t 'iTu5-5uTIl CUN& N N 0 OR i PAYMENT AI Y 1 1 TYifTiNT W � c PITYiP7t riff. , DISCOUNTr 1 t fur. YO IrvOICI DAT[ D[fCNV T10N FUND ONE ACCOUNT CNCVMINANCE NO. P/C ►AYr1[IIT AMOUNT r ." ­Lf'ANAfEE ANDYNr TAfa OPrIOr ACTIVITY I a DISCOUNT 1 _y fUY rD. IrvotcT nArl •-` "•" Of 1C A11TIOM FUND/04i 17C COW NT [NC YYfANC[ 0 P/ PAYMENT T 151 _—�� T1NAf\9 AYOUNT rAiVjTPT-1VNj- ACTIVITY fP[C I\f! DI)COYI11 CONTRA COSTA COUNTY AMBULANCE ' PRE-HOSPITAL CARE FORM I IINII t�� AUTHORIZATION07 ", /� - CHECK OR FILL IN APPROPRIATE SPACES DATE: 1 / PATIENTS NAME_.t OM ❑ F COMPANY# ADDRESS AGE CITY z_- STATE ZIP DOB ❑ Sn ❑ M jkT ❑ W ❑Th O F OS i DRIVER'S LICENSE M _ PHONE NATURE OF DISPATCH ' r' wr7T TYPE OF TRANSPORT:'AMBULANCEM,. OTHER❑ INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME—(24 HOUR CLOCK) ? •rS TO SCENE- O S.O. ,1 CALL RECEIVED 1L ❑ P.D. TIME 146 PATIENT DESTINATION: FROM SCENE-� ❑ FIRE TIME'10-97 LZ ❑ PSAP TIME 10-49 MILEAGE: ! 4OTHER/PVT TIME 10-7 END S , `1 TIME 10-98 _Z DOCTOR PMD/ER STAR7_L �� ` TIME 1422 ;1 HOW CHOSEN: COTAL _/' r- STANDBY TIME ._' '• �'' ❑ NEAREST ❑ FAMILY O TRANSFEq/ WAIT TIME O PATIENT ❑ DIRECT ❑ OTHER f GALL BACK p: AMBULANCNY: PT. AMBULATORY? PATIEtIT TAKEN TO AMBULANCE: RESPONSE ZONE L ❑ YES 4 NO ❑ WALKED O GUERNEY'❑ OTHER PATIENT CONDITION: DRIVEEMT- TECHNICIAN 1 17 PARAMEDIC r- Hx: •�:T-:- ry DISPATCHER: ,- CHIJEF COMPLAINT r �' ` t -r L'DRY RUN: ❑ YES` d NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE)X MEDICAL COVERAGE: INDUSTRIAL ❑ YES* NO NO. OF PATIENTS: S.S.it PRIVATE INS.CO.: EASE RATE: KAISER If: MULTIPLE PTS.BASE RATE BLUE CROSS d: TOTAL MILES: X �• A o' MEDICARE a: E.O.B. ATT. ROUND TRIP: O YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPRP N: EMERGENCY RUN: 'I MEDI-CAL Is: CODE 2/3 OTHER:-- OXYGEN: (PER TANK) - P.O.E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) DATES BILLED:-._ STANDBY: (OVER 15 MIN.) E.K G: (PER EPISODE) NEAREST RELATIVE,'PESPONSIBLE PARTY I V. (PER ADMIN.)__ X DRUGS: (PER ADMIN.)_ X NAME: _ RELATIONSHIP.-_._-___. E.O A.. (IF NOT REPLACED) ADDRESS:___- -__—_-.._ _ ORAL AIRWAY: (IF NOT REPLACED) CITY: _ STATE-__—..ZIP:--.__ C-COLLAR. (IF NOT REPLACED) PHONE: __ _-.__— WORK PHONE:_--..^_ DP./RUN: (AUTHORIZED) EMPLOYER: .___._-__. OCCUPATION:_._ OTHER. ADDRESS:-----"- -- -- - --- -- - - -- CITY.. STATE:-__.__ZIP:-.__.._- RECLIVED - -- - - COMMENTS------" --------"------ ---------..__...__.. .-_-___.__. TOTAL:.---._ ..-_....-:.._. 152 _-CADILLAC AMGULAN PATIF-NT REi Epvu) By X. - - ..:... .. ... . .:. -.-. ... . .. ... (SIGNATURE) I CONTRA COSTA COL AMBULANCE -1 / PRE-HOSPITAL CARE FORM 1 UNIT AUTHORIZATION M -� DATE:. 11.5 ;l f i"1 A ' CNECK OR FILL IN APPROPg1ATF SPACES PATIENT'S NAME._. ❑ M ❑ F COMPANY } ADDRESS - --"-----_(_._..___.--� AGE ` CITU STATE ZIP DOB O Sn,)D M ❑ T ❑ W ❑ Th ❑ F ❑ S DRIVER'S LICENSE e _ PHONE.--...-- NATURE OF DISPATCH '1 L( (,LJ =t'i . TYPE OF TRANSPORT: AMBULANCE)0, OTHER❑ INCIDENT LOCATION, RESPONSE CODE: REQUESTED BY: TIME— (24 HOUR CLOCK) TO SCENE- .) O $.O. CALL RECEIVED ❑ P.D. TIME 10.8 PATIENT DESTINATION: FROM SCENE- n ❑ FIRE TIME 10-97 rr I L ❑ PSAP TIME 10.49 •t''1 ` �"- _ -MILEAGE: P-OTHER/PVT TIME 10.7 END )'n TIME 1098 DOCTOR PMD/ER START 1 L-.7- TIME 10.22 HOW CHOSEN: TOTAL STANDBY TIME ' 1. c SI ❑ NEAREST 17 FAMILY ❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT •1.OTHER I / �,)1 'ti( y.;l,)j Q( (!,(I, C)4LL BACK 0: AMBULANCE COMPANY; . - - 4 - PT. AMBULATORY? PATIENT TAKEN TO AMBULANCE RESPONSE ZONE ❑ YES .❑ NO ❑ WAL .ED ❑ GUERNEY ❑ OTHER ! PATIENT CONDITION: DRIVERCEMT- TECHNICIAN PARAMEDIC qi Hx: DISPATCHER: j 4 CHIEF COMPLAINT: DRY RUN: ❑ YES f©NO REASON FOR DRY RUN Y AUTHORIZATION FOR DRY RUN(EMS USE ONLY) { , PATIENT REFUSED SERVICES: (SIGNATURE) X MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO.O�P\TIENTS: t � S.S. 0 PRIVATE INS. CO.: BASE RATE: KAISER K: MULTIPLE PTS. BASE RATE _ BLUE CROSS q: TOTAL MILES: Xr� 0 f MEDICARE M --_ E.O.B. ATT. ROUND TRIP: ❑ YES • ❑ NO ❑ YES ONO NIGHT: (19:00-07:00) S CCHP/PPRP r: EMERGENCY RUN: MEDI-CALK: __—_...,__.. ._—____-..__. CODE2 3 OTHER:----.-------- _.-....__--_ OXYGEN: (PER TANK) P.O.E. STICKER ❑ YES ❑ NO NEONATAL'. IMCUBATOR) DATES BILLED: STANDBY (OVER 15 MIN.) E K G. (PER EPISODE) t' NEAREST'RELATIVE%RESPONSIBLE PARTY: IV IPER ADMIN.) .._-. ------- X DRUGS: (PER ADMIN.),_-. X NAME: P.ELATION SHIP: — E O A : (IF NOT REPLACED) ADDRESS:.---_---_- — ORAL AIRWAY. (IF NOT REPLACED) \� CITY: —.__ _ STATE._-_—ZIP:. C-COLLAR: (IF NOT REPLACED) —� PHONE: . _—__ WORK PHONE . _ DRY RUN: (AUTHORIZED) _ EMPLOYER: —_—_ OCCUPATION'__— OTHER: ADDRESS:.—__...---- - --- — \ CITY: STATE:___ZIP: __— COMMENTS:—_—_..—.—_-------ItECE1VED - - --^-- . ----- -...—.—...------ .....------- TOTAL:--.-=_ =-- 153 _—._ ...-- ---..- - .---_--__-- PATIFNT RECEIVED SY: X, _ _..•:.r ..+:i Err:.•-: r. ,: (SIGNATURE) FjIc.1 CONTRA COSTA COU I: AMBUUNCE +! PRE-HOSPITAL CARE FARM I 1 UNIT AUTHORIZATION III Y+•I• �r CHECK OR FILL IN AFPgOFR/AiE SPACES DATE: t•' f�"�I�3 'i� i �''� �ATIENTS NAME— r/in a �=i'•:- .. i FL DNI OF COMPANYN wADDRESS { AGE 7. J.y4 a i ;-CITY STATE ZIP DOB D Sn O M O T O W O �• S- ?DRIVER'S LICENSE q PHONE NATURE OF DISPATCH jYPE OF TRANSPORT AMBULANCE❑ OTHER❑t y - I .+ INCIDENT LOCATION " _ " RESPONSE CODE ;V: REQUESTED BY .° TIME—(21 HOUR C OCK) t c+; [/J� TO SCENE ' i,' ❑ S.O. CALL RECEIVED",�G�s Sr Al2(9�/JT j1l,1At51 d� �AM= � . D P.D. TIME }0 8 rr PJ�TIENT DESTINATION: FROM SCENE- D FIRE TIME 10.97 ' 2 . O PSAP TIME 10-49 ` rrA L MILEAGE: t ❑_OTHER/PVT TIME 10 e : . > END (1 G. (l,.r .,.o!, TIME .Ri;DOCTOR PMD/ER ' START `' t� TIME 10-22 �',�if` :.'`` " f—S fes-. n SHOW CHOSEN: STANDBY TIME J *y {. D NEAREST D FAMILY 0 TRANSFER-,. WAIT ❑ PATIENT ° O DIRECT ❑ OTHER CALL BACK M: AMBULANCE COMPANY7y1`� ' rw PT. AMBULATORY9 PATIENT TAKEN TO AMBULANCE r k•t1 t° ` Is _ RESPONSE ZONE' ?' O YES ❑ NO O WALKED O GUERNEY '❑ OTHER P r' ,PATIENT CONDITION: It.'DRIVER__-�5rc ru itA� K.. ' � EMT-1A TECHNICIAN a PARAMEDIC F' Ax. ' DISPATCHER: 5CHIEF COMPLAINT: DRY RUN: D YES D NO REASON FOR DRY RUN ~ S r 3 �' "/ +� +�E 4 AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES:(SIGNATURE)X II G'MEDICAL COVERAGE: - INDUSTRIAL,❑.YES ❑ NO NO OF PATIENTS: atzc [.tl.0 LrL a PRIVATE INS.CO.: " " BASE RATE: ' 'KAISER M: MULTIPLE PTS.BASE RATE BLUE CROSS 0: TOTAL MILES: X Q'��� • ', t �R MEDICARE K: E.O.B.ATT. ROUND TRIP: O YES O NO O YES ❑ NO NIGHT:(19:00-07:00) r CCHP/PPHPN: EMERGENCY RUN: MEDI-CAL#; CODE 2/3 ,, OTHER,.- OXYGEN:'(PER TANK) ,,. '' ♦' ' i P.O.E. STICKER 13 YES ❑ NO NEONATAL: (INCUBATOR) ) `d DATES BILLED: STANDBY: (OVER 15 MIN.) �1 `� E.K.G.: (PER EPISODE) 3 { . ...,,NEAREST RELATIVE/RESPONSIBLE PARTY: LV.: (PER ADMIN.) X I r6 r DRUGS: (PER ADMIN.) X t' S} 4 , lar'14-NAME, RELATIONSHIP: E.O.A.: (IF NOT REPLACED) -i-.ADDRESS: ORAL AIRWAY: (IF NOT REPLACED) CITY: STATE_ZIP• C-COLLAR: (If NOT REPLACED) ... �• >. PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) t, _ EMPLOYER: OCCUPATION: OTHER: - 4�,'' �; ADDRESS: ...... STATE* ZIP• _ 4"4 is 1 ,COMMENTS: o[rrI I ^�=..... `( AUG 12 198Z TOTAL: 154 CADILLAC AMBULANCE PATIENT RECEIVED BY:X '�' rbn•+i drr rr .cci r. 0--i[e mld Pf-1. mpy Rrtnm )r:filar n-;y k rpt chrn Fi:iino (SIGNATURE) CONTRA COSTA C&TY AMBULANCE . . —'r I J PR_FSPI HOTAL CARE FORM I' UNIT AUTHORIZATION 1a ii �'.a•_ CN[Ck nA Lill IN APPROPRIATE SPACES DATE: PATIENT'S NAME :-:.__._(y_ _��._._� C�f...S(j,:��').`-2i� ❑ M ❑ F COMPANYN •� ADDRESS — _-- AGE :a CITY_ _.._ ..___......__._._._.. STATEZIP_._---. DOB — 13Sn 13M ❑ T ❑ W KTh F ❑S DRIVER'S LICENSE a _ PHONE. NATURE OF DISPATCH TYPE OF TRANSPORT: AMBULANCE❑ OTHER❑ INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME—(24 HOURCOCK) (!.? C I C TO SCENE- ❑ S.O. CALL RECEIVED __L/L1__ r )i�;. ---J� —, ---• ---- ❑ P.D. TIME 1G•8 } _ PATIENT DESTINATION: FROM SCENE ❑ FIRE TIME 1497 '. ❑ PSAP TIME 10-49 _L'--' YL� MILEAGE: lqOTHER/PVT TIME 10-7 1 J END TIME 10-98 _ ` DOCTOR PMD/ER START TIME 10-22 ' 1 HOW CHOSEN: TOTAL { STANDBY TIME 13NFIREST 13*FAMILY ❑ TRANSFER T� 1 I WAIT TIME ❑ PATIENT ❑DIRECT ❑ OTHER � CALL BACK M: AMBULANCE COMP PT.AMBULATORY? F�ATIENT TAKEN TO AMBULANCE: RESPONSE ZONE © VES ❑ NO KED ❑ GUERNEY ❑ OTHER PATIENT CONDITION: DRIVER EMT-1A TECHNICIAN cl IRt L- PARAMEDIC Hx:— iI ` DISPATCHER: •...'T� .y,� . - CHIEF COMPLAINT: S"r I (� DRY RI IN: ❑ YES NO REASON FOR DRY RUN _SLY1i)>,2�LL AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES:(SIGNATURE)X ; MEDICAL COVERAGE: INDUSTRIAL 13 YES 13 NO NO.OF PATIENTS: h, j�J•' S.S.a PRIVATE INS.CO.' BASE RATE: KAISER It: MULTIPLE PTS. BASE RATE O � BLUE CROSS It: - TOTAL MILES: X • � T - J�• MEDICARE 4: E.O.B.ATT. ROUND TRIP: ❑ YES ❑ NO ❑ YES ❑ NO NIGHT: (19:00-07:00) j CCHP/PPHP 4: EMERGENCY RUN: 1 . (j t'• MED)-CAL tl:— —_ _ CODE 2/3 OTHER:—_ _—_—._. OXYGEN: (PER TANK) a P.D E. STICKER ❑ YES ❑ NO NEONATAL: (INCUBATOR) U DATES BILLED:_— _.— STANDBY: (OVER 15 MIN.) E.K.G.: (PER EPISODE) NEAREST RELATIVE'RESPONSIBLE PARTY I.V.: (PER ADMIN.)— X DRUGS: (PER ADMIN.) X ' NAME'______ ._....____.— RELATIONSHIP:..__—___ E.O.A.: (IF NOT REPLACED) �f ADDRESS:...—_._. ORAL AIRWAY: QF NOT REPLACED) r t'. CITY. STATE--__ZIP:___ C-COLLAR: (IF NOT REPLACED) ;}1 PHONE. _..—._—...____.._— WORK PHONE'_.._.._—__—.._ DRY RUN: (AUTHORIZED) EMPLOYER: ....... .......-. OCCUPATION: _—..____..___ . OTHER: >: Ll ADDRESS:..._.. . .. .- - - .. ._..--- _....- -- —_......—._... ------_.--- --- CITY......- ---- -------. _.. STATE -- . ZIP'.---- ----- ---- ------- RECEIVED -- "- - --- COMMENTS: .. TOTAL' CADILLAC AM13ULANCE .i ' •. _.. _ . ._ . . PATIENT RECFIVED BY:X...... Tl R .:} .• I 1 - ( NA E DEMAND NO. 231 c "141'" No "111.U ",-�,J On Me .1rf n5t11.•4'f Illi , COON Il' (11' ('UV I RA ('OS IA 11ro-sented BY: STA I t:or cALIFORMA DATE 6-30-82 s+ t I CADILLAC AMBULANCE SERVICE, INC. N•Yt IL \T) IT IRS r ::••, 1\1PUR'rA.NT � 1 4601 'NEVIN AVENUE ke In>truclinns cm Reverse Side *ooRICHMOND, CA 94805 CONTRACT fi 22-079-8 cl*•� a*�*[ [licoot DATE: . 7-1-81 to 6-30-82 r .#. For the sum of ***** I' E THOUSAND SIX HUNDRED SEVENTY FIVE AND 70/100*** Dollars = 19675.70 -- — As itemized below: . UNCOLLECTIBLES DATE DESCRIPTION AMOUNT t ---- --- -- SE ATTACHED2 y J. PAGE _Emergenc�A� . uices— • ��� _�u>✓�t"LCL_ Q% (���� -- --- _ r,� •: �msr0e"cY Mcdfcal service- RECEIVED r. - -------•- --- AUG •� CA ILLAC AMBULANCE ? The undersiLned under tIn• pi lialtc (if petjury mal" That the above claim and the items as therein set out are true and correct:,. chat no pact thereof has b(•en hcleulfute paid, and that the amount therein is jusII.- hit and that the safne is presented within one w Lear after the last item thpro(lf has ar•cnled• Signed VENDOR N0. Receivrd, ACC epled , and Expenditure Authorized /L'•_- -�•- _ • •J•• .—.- -''- of"c•erri++rli •0 1 o[rvT.[ ..�.=�'. lug'GL' JFttTE7R G[Tt'n l G73xt-r At OU Lc�N N No .. c { TY + AMOUNT j r r ' tiled 7Y irT iI' rlFi c Vltr r.lc •L\f olf Coulli •' l FFM dun. tO. I+VO.ct DAT[ Ol•t Cr1�T10■ ru�[ EA-tE+11RARct e0. r/C PAINIYT •YOVeT �f.eL •YOYeI TT ( 1111COUNT. { , r r \UY e0TIN 01tU j{'T 10� ►YrtO Oft KCOY+T tec YYrf♦+C[ YO •/[ I1TY[YT •YOWT { r —Ll. r •TU MII tY0V+1 7"'L 710+ •Cllr ll♦ f.IC rvrf OHCOVh l i- _ (OIS n.r TizTi � . 1 + e? f r..•1 .! � t Iqf 000 tt i e P CONTRA COSTA COUNTY AMBULANCE aziL RE-HOSPITAL CARE FORM 1 UNIT I ( ' AUTHORIZATION N CREC/ OR FILL INAPPROPRIATE SPACES DATE: ' {5" -PATIENT'SNAME •. r r .' 11_•A�.lC�- ❑ M pF COMPANY N cw�� ' ADDRESS /�+� -r -� - AGE__ C�'_ Ii CITY_,. Lj-1��I STATE r 1__. ZIP �' OOB1 -�t' U Sn ❑M ❑T..�W .13 Th O F:O DRIVER•S LICENSE p ,(• .1.. ' " " PHONE r��' •..;�i: �_ NATURE OF OISPATCN� •.•'�4 • ! r 7 . �?+ - TYPE OF TRANSPORT: AMBULANCE4 OTHER _.. s,.. ;. INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME-(2/HOUR i. TO SCENE O S.O. CALL RECEIVED. j `�,.kkt.P•;. J . 1 !r f•'1 ��. 1: :/._ 1 /-/Y.1 ••J � ,�� 1 O P.D. TIME 10-8 z'w `• � 'r NT DE ;TIN TION: FROM SCENE- O FIRE TIME 10-97 ' O PSAP TIME 1019 I,) / (' '1''•I 1f �. I MILEAGE: 0TH R/PVT TIME 10 7 i;' r. /l . ' r,: ' ¢ _ END / I �iv 7!.// . TIME1098:i1l� l DOCTOR_�/ L 1 PMDlER START. ` r . )'J TIME 10-22 r - 9 :e LR. HOW CHOSEN TOTAL �) STANDBY TIME'q L7 NEAREST " I7 FAMILYO TRANSFER WAIT TIME O PATIENT- . O DIRECT ❑ OTHER '' CALL BACK U: AMBULANCE O P¢NY •�~ ',' PS<AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZON YES tt NO O WALKED ❑ GUERNEY O OTHER _ > �; PATIENT CONDITION: DRIVER I ���i�! {�� (t MT_19 � r� .< -+. S`�'`r�;• s TECHNICIAN �/f J� PARAMEDIC •' " ' Nx, ,rr r`h s CHIEF COMPLAINT: JLI DRY RUN: O YES 10 NO I R ASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY)— PATIENT NLY)PATIENT REFUSED SERVICES:(SIGNATURE)X ll MEDICAL COVERAGE: INDUSTRIAL O YES AU NO NO.OF PATIENTS: s SS 'PRIVATE INS CO:_•'�! (� � �i� /// ' BASE RATE: .s.�Z'+7S • F KAISER k: . MULTIPLE PTS.BASE RATE ' r, I BLUE CROSS A:_ TOTAL MILES: X MEDICARE s: E.O.B.yA,TT. ROUND TRIP: O YES O NO ±; 13 YES i4/ NO NIGHT:(19:00-07:00) �:. . r i. iftw 7• .. CCHP/PPHP 0: EMERGENCY RUN: j 4 MEDI-CAL p:_= - -- CODE 2/9 j( OXYGEN: (PER TANK) 1: ' P.O.E. STICKER ❑ YES O NO NEONATAL: (INCUBATOR) DATES BILLED::�:�U,S a =1 ���.�L(P=F_L STANDBY: (OVER 15 MIN.) E.K.G.• (PER EPISODE) Y: it i' NEAREST RELATIVE/RESPONSIBLE PARTY I.V.: (PER ADMIN)_. X ,y," DRUGS: (PER ADMIN.)- ':X ' f I NAME( '4�1 .J, 11 I RELATION SHIq;U-1 �f r E.O.A.: (IF NOT REPLACED) �s T ADDRESS L_.. ` _.� 1� L 1_� 1 ^" 1(f ORAL AIRWAY: IIF NOT REPLACED) CITY: �t___ 1 r - ___. STATE ZIP: C-COLLAR: (IF NOT REPLACED) a PHONE' . w -1- 1` WORK PHONE:_- DRY RUN: (AUTHORIZED) EMPLOYER; _._ .`_..__ __ OCCUPATION OTHER ADDRESS: . '., CITY.:��-- --�- STATE: ZIP: ----�- i � t s 1' COMMENTS.. ^ 11111 +' 41-1 TOTAL:. CADILLAC ` .` 1,5.71, ��_s-i` _. PATIEtJT RE�ftVfD BY:X `''i .. _..�_'•' (SIGNATURE) :.,,;y i ..Y;-OA-1 1 1)I:A1;�NI1 DEMAND N0. 192 .' _ vcNnOA _. I4m/ Thr lrtecw of the Y COUN 11' t)1' UO.N 1 RA (UIS I A ' Present.ed By: S'IA1I-' OF CALIFORNIA DATE MAY 4 , 1982 " CADILLAC AFIBULANCE SLRVICE, INC. MAut uAIri IrINOT) IMPORTANT ,' ' •'' 4601 NEVIN AVENUE Sto.Instructions on Reverse Side AVONIE 53 RICHMOND, CA 94805 CONTRACT # 22-079-8 I e1Tr, STATE . :1.eDDc DATE: 7-1-81 to 6-30-82 )F, 1 17 i For the sum or ***.ORF—IHDUSAHD-lUn JiUlIDRED FORTY TWO AND 20/100******* Dollars $ 1 ,942.20 :•.;< "'' Ns itemized below: UNCOLLECTIBLES ! DATE DESCRIPTION AMOUNT — LI 1. )r SE•E ATTACHED RECEIVED 1 -- AIG S� MAY ? 1982 Ih �FjGlac�t 2•Tr2_// !(r� q5 J _ ergency Medical Servien nw —Cc[C71 xj Cfi;?,l,i?)r 0 0 0 ,, RECEIVED • . ►; Crr.oroentYMeeirflServicesAUV 1 ' 1 82 • t � ,. 9 9.� 112.50 ' /43775�_19�3�'�' CADILLAC AMBULANCE 1— v Nledlcal Services - 1 1 19 �' �. lI�/ q5-3 20 _195 , 1"75AI) MAY ' t ' a The undersigned under flip plalalic of perjury states: That the abort- claim and the items as therein set out are true and correct: i. it no part theroof has bi-en livretolilre paid, and that the amount therein is , 11 dyl•. and that the same is presented within one ar after the last item thereof has accrur:d, — _----•---- - Sit;necccctttt'"' .��1t.:<�•i+J .—s''r"'`�-_ lENDOR NOn Received, Acceded , and Expenditure AutAozed OVittTr[N7 READ ON CNIFr Ot PYTJ. (IMITT I-1704 A CC OU uri7rZiL N i c ' P Tr N r u y� ��5i ^s•t1 _i TA to,ff M OPTION C1 ITITT Or[C INf. + - DISCOUNT t 1 1 r0. INVOICI ON 0[SCPIPTION PUMP one ACCOUNT tNCUSIONANCI M0. P/C , PAT Y[NT AND UNT / . 1 -TyAAASL AMOUNT TAS- YTION ACTIVITY DISCOUNT . 1 1 , 1 ■o. trroic 'ail " `""'viii+�+io:V FUND/040 w0 =uc`ovNT- tllcurrPANCt INC P , rArrsaT Ar 1 TUr ASIA AouNt (—r./■ o;noN topic rlPf DucouN SIR NOr )I.., l r } CONTRA -CO .W. COUNTY p$E-HOSPAAL CARE RT I. 1, r ` `•. `' " . DISPATCH INFORMATION TIME (24 HOUR CLOCK), / MILEA9 /�• CaII Received: End '✓ ' NATURE OF PROBLEM ( i�T� J las dispatched) ir , I _�..�_•L-�l.� ,,, Time 108 ! i t :_T_ Start • ' �yt INCIDENT LOCATION Time 10-97 �' / f Total Time Addres.: o:c�l<3:L. �jl . r .r�z�l t _1J r me 1049 = rL: s RESPONSE CbDE .I •tp.=CitYi Cross St.: ' ' I Time 10-7 !'L"�� J-p:, To scene `. Time 1098 (1 'l .� �q '• ,,:tc `.L'n i / Call Beck No:' r + s �j•, Requested By: [Is.Q,DP.D,0 Fire eSA Time 10.22 from scene {.-,Other/PVT— •1 Standby Time _ '1\ PATIENT DESTINATION "1 "` Welt Time ..r �- .�f : ����+� � 4 ; Cancelled By lrr How Chosen: Dry Run: Yes ❑No ""K •'' 'n4+� r❑Nearest ❑Family U Transfer : Reason for Dry Runtoll ! ... ty E)Patient ❑Direct Admit ❑Other Authorisation for Dry Run(EMS Use Only) "EMT-11A) Unit No. . a f+t +. t PATIENT/BILLING INFORMATION ' y.fy Paramed( Unit No.: Driver �.. ,tt Patients Name: •: ;� t iAge: Attendant _ r MOF;' D.O B �1 Dispatcher L.l• i ,.'ij1 ,• 'Address:; i ,'. "+ r• _ 1�-�C`r it �. �. ; '' Type of Transpon:,Ambulancerheelchair/Car - Ambulance Company: -iCity:` f `- t c'1 -1' y• I g } -.+State: Zip:LL ❑Antioch ❑Morapa Ftrey� t` RESPONSE ZONE' ? � y- 02 0304Phone. S.S.No.: X. 0 1 • }z t¢,tt • ( IF .. ❑East C.C. OTri-Cities • 05'.'06 ,0'+ t7`t !,❑e J. uption:Oc ❑Michael's DValleyFire 9.t 13 10� - .. . , Pt.Seen by PMD:. M.D. ••,ti ; ! �' r _ t that Physician: %, M.D. tom . i 1 t;Ar RESPONSIBLE PARTY ty Base Rate: It pt.) - Name: t ; .y EY. 11 of 2 pts.) : d i7tr. s s•�:.fielationship: (1 of 3 pu.) ^firm Jp• 11 oipts.) • 7AWretsi Total Miles X = ❑. O ,Cl State: Zip: Round Trip , tY, Vfc � ;.. ❑Yes 0No ,•-r Phone: Occupation: 4^ Night 17:00 p.m.-7:00 am.) ''�r'•7�0 Work Phone: Employer:'•\ (emergency Run Code 2D, : Address: Code 3 "5`• - t . City; State: - Zip: Oxygen(Per Tank) MEDICAL COVERAGE INDUSTRIAL ❑Yes [,1 No Neonatal(incubator). — ! ` Standby(over 15 min,) " ❑� - '.Private Ins.Co.: - EKG)per episode) ''` i .... -•tet{: y: : I.V.(per admin.)—X Ks y�T+ �.� Drugs (per admin.l_ Kaiser No.: ._X lq , Blue Cross No.: EOA(if not replaced) •"my'� , .r • Oral Airway (if not replaced) n (Medicare No.: �'' . E.O.M.B.Attached ' ;` CCollar Iif not replaced) $y ' \ ❑Yes ❑No m.,�; ;. Dry Run(authorized) CCHP No.:,.' {s Medi-Cal No.: .tither: POE Sticker 0 Yes L)No '._..Dales Billed: t ' _ -- EIt/ tal:_ RECEIVED �. Y ! AUG 1 '. 198 155MAY 20 1982 .. ' I rAPII I Ar. Af11,ULlt:i, CADILLAC AMBULANCE' RMBULANC p COTRA:COSTA COUNTY PRE-HOSPSAL CARE FORM I UNIT / -J AUTHORIZATION E CHECK OP /ILL IN APPPOPPIATE 6PACR5 DATE: I'"Ip t,f :':PATIENT'S NAME ) . L � r MOF i :*ADDPESS } Q Wil` COMPANY 0� (•.. Sly _ r + AGE CITY ! STATE '. .' ZIP'! DQB .14 • (b ❑Sn a Of �1 []Th QF DRIVER'S LICENSE # PHONES 7,L,. � l �yURE OF DISPATCH i .o TYPE OF TRANSPORT: AMBULANCE OTHER Lj INCIDENT LOCATION: RESPONSE CODE: . REQUESTED BY TIME (24' HOUR CLOCK): TOI SCENE- O S.O. CALL RECEIVED. ' TIME' 10 8 , I .75 :�i2. PATIENT D TIN/�TION: 11 FROM SCENE . o P'D' TIME 10-97 �:�. i1��i���1 ❑-FIRE TIME,10 49...«., TIME-10-7 =' '•la L' : ' MILEAGE: PSAP[� .. ',• D >_ —FMD7 E END - ? O E TIME MOW CHOSEN•• _0 " THEA/ VT. TIME 10-22'' STAR f STANDBY TIME TOTAL r.0 NEAREST FAHILY' fRAi+SFE `� — WAIT TIME ❑ PATIENT DIRECT E] OTHER�.,_�( CLA 3.A _CALL_ BACKV: AMBULANC COMPANY," ar PT..,AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE ` Q YES Q NO_,. aALKED"CQ U' ERNEY aTHER " ;.'PATIENT CONDITION: I . DRIVER c-, [� G1� •'_ 1 /fid rEM�1� '' :`:'Hx: I •� . ;_. I; . `..-/ TECHNICIAN(. ,t,!.4__. 3_.c r.._, J�:.ru� PARAMEDIC �-- . DISPATCHER mut:lrtl -�— "'=`• CHIEF COMPLAINT: r �� '/ n•. 1 c" e_DRY RUN: YES Q NO REASON FOR DRY RUN ' ct` AUTHORIZATION FOR DRY RUN (EMS USE OhZY ' PATIENT REFUSED SERVICES: . (SIGNATURE)X �adM` MEDICnALS COVERAGE: _ INDYSTRIAL YES-0NO NO OF PATIENTS: it'd. S. , _.�4. {, •�j. f �i y,Sir 4' 14 .,;,PRIVATE INS.. CO: : BASE RATE: ;KAISER P: :MULTIPLE PTS. BASE. RATE BLUE CROSS th -TOTAL MILES: .0 R,`'' B•0 MEDICARE 0� �''r ' = 0`7 E.O..B. ATT. ROUND TRIP: [� YES NO;'`°f4elf YES NO NIGHT: (19:00-07:00) .;CCHP/PPRP EMERGENCY RUN: ;I ;r" �• 0 MEDI-CAL 0: CODE(2� / 3 OTHER: OXYGEN: (PER TANK) ;.+P.O.E. STICKER M YES NO NEONATAL: (INCUBATOR) '!* DATES BILLED: L`-) 1. /o- •'S- C 20.<"-Of-9 STANDBY: (OVER 15 MINS.).. ': E.K.C. : (PER EPISODE)` r' NE'rr 1 EST RELATIVE/RESPONSIBLE PARTY: I .V. : (PER ADMIN.) X _ p pY f%1,• ,, t. •.i `��,•.!G1 �, DRUGS: (PER ADMIN.) X •' ;, ,. NAME: f RELATIONSHIP: I �.O.A. : (IF NOT REPLACED) ADDRESS: r ' ORAL AIRWAY: (IF NOT REPLACED CITY.: " STATE ZIP: C-COLLAR: (IF NOT REPLACED PHONE:; ` r : ' ' ` WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION: OTHER: ': '{ .ADDRESS:' orrrivrnl' CITY: STATE: ZIP: MA 2Il 2 ..COMMENTS: 'ED _ MB LANC n l I I t r j'•U ' TOTAL: 71f, ("`• ,ti�i'j. S CADILLAC AbiR II Ai i( iPATIENT RECEIVED BY:X% ' "' rr• i :('Signature9- MAIM il► DEMAND NO. 226 !; r vCNDOR N0, A 1' 3 .4 0 ( D..0..0 • on tilt •trennlrl)'of the • ri'r OLKI Y 017 CU ' ( 1 It COS FA ,t STATt;01: CALIFORNIA 6-24-82 , (resented By: GATE ii if CADILLAC AMBULANCE SERVICE,__INd,. '. NAME hurl pl+ni IMPORTANT i 4601 NEVIN AVENUE See Instructions on Reverse Side ACOME ss RICHMOND, CA 94!'Q5 CONTRACT # 22479-8 CITY, ,TATE :1. eooE DATE: 7-1-81 to 6-30-82 S j For the sum at "'"ONE-111O1lSAilILSEVEN HUNDRED FOURTEEN AND fl """ 5,L]110 Dol l o r s = ,1,.714,,-05_ I• As itemized below: UNC_OL_L_E_C_TIBLE_S DATE DESCRIPTION AMOUNT S tE'�ervicr �� Jq PAGES .t REbEIVCp 1.QA? ,I mergenc A�123�p��I � 21�1�(o�D?►2. q� a/.?39����2r�./� YMedicalServiceq �•: I � LCE' (hte �1•�„ l 33� G�-y . .I 1987 . �� �! y p g /M/ /r i( At (,G'" ��_LC 117 ZAV x x CAD r1 The undrrsigned under ihr pen Ily of of perjury states: Iiial the ahVve cla n and the items as therein set out are true and correct; 'hat no part thereof has been 1wretofore paid, and that the amount therein is ju dre, and that e acne is presented within one car after the last item thereof has accrued. 5 ;a Signed Aitt,:�t a VENDOR ne. Received, Accepted , and Expenditure Authorized I .. Ocnetllt+i 1"TiIty UrfG7o>ii. c ou F rilfITiE r .. c 1 PATWLMT AMOUkT '—'TkTl,t'L r iTi" o ?ib'ii c Ylrr Isere rLas. , olscourr t � t . X. 20. INVOICE DATE ' OELCAIr T1oL DUND OAL. Ac COUNT alcur LAANCL NO. L/C ` ►AININT AMOUNT r � r TARAILT ArOYar TAS, D/TIO+ ACTIVITY DISCOUNT 7r r0. IrrO1CY �"" - --- -- --DrjCAjf110+ FUND 0011 ACCOUNT arcurLlAreL ro. r/c ( ►irrul ArourT 1 TANANI, Ar00Nl TALI 01710+ ACl1Y1yY EC FLI 3.1 DISCOUNT j . 1 (Dig Rev. 7/77) CONTRA COSTA COUNTY AMBULANCE � ' , .7 33 11 PnE-HOSPITAL CARE FORM 1 uNir / AUTHORIZATION e 1 r-rret,rnxlrureAnrr+ovRIA rrsrrarrs DATE: L. PAJIENT'SNAMEL .L/J _ _ _ _.___ ❑ P,1 Jp F COMPANY °R +y ADDRESS -----P��-' CITY(•,.LIL.f(f_ 1 _ STATE-L 4__ ZIP���c _ DOBl�Erlk.(,P ❑ Sn (8 M OT O W O.Th O F �•g ..s DRIVER'S LICENSE a -____—__ _.. .._ PHONE'�>!__L(��- __ NATURE OF DISPATCH ( TYPE OF TRANSPORT: AMBULANCE.11 OTHER 11 INCIDENTtOCATION: RESPONSE CODE:-. REOUESTED BY: TIME—(20 HOUR CLOCK) v '+ TO SCENE- ❑ S.O. CALL RECEIVED y; �� ,S ��1 i,r�/:.-• �/i I '/r __ ❑ PD. TIME 10-8 :. .'=:. P. 5: fit . . PATIENT DESTINATION: FROM SCENE-J; ❑ FIRE TIME 10.97• 's •ff " 1 n 4 11 PSAP TIME 10649 'i L L1C.'�L(L-CU. �ll3c It MILEAGE: OT1 1. ��HER/PVT TIME 107 {. END C. 'I �n. .TIME 10-98 r 1'1`Z t 11 ; � ,• DOCTOR1 PMWER START_L.( �.�. TIME 10-22 Y sr 7' ,r—fir r--• ) r) HOW CHOSEN- ! 1 TOTAL —1 ._�'_ STANDBY TIME ❑ NEAREST 0 FAMILY D TRANSFER WAIT TIME ' }1 ? ❑ PATIENT .,.-❑ DIRECT ❑ OTHER; ' CALL BACK X: AMBUIy4NCE C qNY ° i r r•' PT.AMBULATORY! PA-I'NT TAKEN TO AMBULANCE: t' 3 ` RESPONSkZON YES ONO ❑WALKED b GUFRIgY ❑ OTHER .��• RATIENT CONDITION: DRIVER_ (CI. EMT-tA (4_w� -_� 3 r r tECHNICIAN .! I / ,r) + PARAIUIEDIb r , ra' 'P•• ll' ' '1 Qr�q • x: HDISP.ATCHER: U!..!�••' ' .(IL•,�_J I 11 H EF CO PL/,'NT. /. . ) !! .) !' r I(� )111 -� I. G DRY RUN: O YES <� NO REASON FOR DRY RUN 1 11 •'1 AUTI!)ORtZAT10N FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE)X r4 1' r MEDICAL COVERAGE: INDUSTRIAL ❑ YES ❑ NO NO.-OF PATIENTS: f F 8 "t PRIVATE INS.CO.: BASE RATE: KAISER If: MULTIPLE PTS.BASE RATE °! BLUE CROSS 4: '+••(�' % �'-� % TOTAL MILES: `I X::'.:.�Z.��'! «. 2 3 ,!• r!j MEDICARE a: E.O.B.ATT. ROUND TRIP: ❑ VES ❑ NO ❑ YES ❑ NO NIGHT:(19:00-07:00) CCMP/PPRP a: __._,.__—.!_ - EMERGENCY RUN: ;,• . • '� MF.DI-CAI.a: CODE 2!3 .. OXYGEN: (PER TANK .. - . OTHER:.._._..._. .... ........_.... :. .----'-_._._—. _.__ - � ) .. PO.E. STICKER C1 YES ❑ Ni) NEONATAL: (INCUBATOR) .''•„ DATES BILLED: _3. L��S y��L=�2rS=/2�1 J STANDBY (OVER 15 MIN.) F.K.G.: (PFR EPISODE) NEAREST RELATIVE/RESPONSIBLE PARI N*: IV.: (PER ADPAIN) DRUGS' (PER ADMIN.). X NAME.'�`_''.�.I:._'__�_i�.).: -_ RELATIONSHIP411 i ` � r_ F.QA.: (If NOT REPLACED) ADDRESS:��+�—• -.�._-_ ORAL AIRWAY: (IF NOT REPLACED) -�' '�• CITU:_. ! ' , _.: STATE._ZIP:_ - f:-COLLAR: (IF NOT REPLACED) PHONE;!'.!• r' •-j-Jr_-._-_- WORK PFIOIJE:..__ DRY RUN (AUTHORIZED) �••" ' r•�,4� n EMPLOYER: OCCUPATION: — OTHER: ADDRESS: _ __.._. CITY: _- ..._------- STATE:_,.-.ZIP;- COMMENTS:­ ­ TOTAL. /4,S.LS CADILLA Pf:CFIVF.D RY: K - '.0•(� :...... ;• �..,.. .' . Ip} ... (SIGNATURE) .I FAParn'341t.:• +,Pp •. .. .. ?i —_ - .... . . . ULhUti,5 NU. 144 ./� III•:At;1 SII F A • vi tlbnn No _ 3 _. *n the rtheU, 13 f.: :1 1' U17 ('0N I RA ('US I A ' F'tesented By: S'IA'IE017CAI.II.ORNIAGATE 7-8-82 ?I CADILLAC AMBULANCE Sf RV10E,__1NC_ NAY[ Il Alf1 IMPORTANT 4601 NEVIN AVENUE 3.: See hl%nucGnns on Reverse Side - •oont�l RICHMOND, CA 94805 CONTRACT 4 22-079-8 CITY, STATE ZIP coot DATE: 7-1-81 to 6-30-82 ..tt.. ., 1 1 1 1 1 1 1 1 1 • ' �I For the sum of _****{*_ONE_ THOUSAND THREE HUNDRED SEVENTY THREE & 05/100 Dollars $1,373.05 w ; As itemized below: UNCOLLECTIBLES ' DATE DESCRIPTION AMOUNT -- -- - inn%fARDED I (rcrp^rcy htcdiral;ervlcr^ ' ' •#� SEEATTACHED y; - '�Les � REGEIb'ED C -----3333-� _ Ernq��encyld&licef I .� i4�1 I 91 4S 56 —°-7 s &ft dYG�R(�fc� Q� �_���„C#��_7�.b� du r. ,�r�s�Q��� ECEIVED . CADILL C AMBULANCE The undrrsiptted under thl' penalty of perjury states: That the above claim and the items as therein set out are true and correct. that no part thervof has hvvil hi-retnfoie paid• and that the amount therein is jn§4 dut, and that the carne is presented within one ! vear after the last item lhereof has wertwd. / L/ Signed _ t 1, VEMDOR No. Received, Accepted , and Expenditure Authorized O[IARI M[K7 M[AO OII-LIAIEC of/u7'( Y' rYV'LE- 1arT — tntrlrnbF— PUN 704AOUN NCUNDR010.. . t ( YN , AMOUNT I 5/41-2-J-6 7 1 , Axfii IVOUNIT JOPTIONI ACTIVITY 11PIC IN1. DISCOUNT 1 1 , ' I ,VII ■e. INVOICE DAII ... Ot1CN11T10N FUND/ORO _ ACCOV47 I IINCyNINANCI ■O. ►/C 1 PAYMENT AUGUST 1 t.EAEI AMOUNT TAIL YTN)M ACTIVITY DISCOUNT , 1 .re- -- IUM NO. INYOICZ D'7Tii Of IC NIf TOOK PyN*/011 AC COVNT [NC YYINA NCE NO P/C ►ATMI NT AMOUNT •TU AII[ AYOVKIM1A OPIICI ACTIVITY IIIC IU! 011 O (015 PV. 7,17) I •' ; ��— FEEM ' , .T - . • . t, . rL. • COt+TRA COSTA COW At,+Ri11.ANCF • �I'� . FRE-HOSPITAL CARE FORM I KNIT AUTHORIZATION N rf 1. 1:1TI t:ner„ttoenttresvxers DATE:�__L.�c7 Z PAI"IENT'S"NAHCT77�-ia _ �• ' -C,r--- 'N `. ,�;4, ,.. "•:" --C .___.. r�.ic .PSM I1 t” COMPANYN Z-;y-�.1//Z ' .. , ADDRESS -1=1 1_ _ l pl 1�1�-J t )fr. AGE V CITY_t_'`,-'`,- yy�,t�'(� STATE_i f- L,r ZIP D Sn D M D• T jp w. D Th O F;' S f DRIVER'S LICENSE N. PHONE;.�Y_�_'' _'NATURE OF DISPATCH 'ii - TYPE OF TRANSPORT: AMBULANCE D OTHER D ! n INCIDENT LOCATION: RESPONSE CODE: 4E01IFSTED BY: TIME-.(24 HOUR CLO�QK) 4y„t ti . TO SCENE- DSC.__ CALL RECEIVED. ” b' O rn. TIME 148 PATIENT INA FROM SCENE D FIRE TIME 1497; s'. ' .thxi z' 7 . I ,� ❑ PS TIME 10-49 r ' tyi'f MILEAGE: F7 OTHEi PVT? TIME 10-7 t�: I M I END� 1 __z__y__ TIME 10-98 ;1{ ,DOCTOR PMD/ER START.�lZ� �; ��•;+ ! I TIME 10.22 ) =� +aj HOW CHOSEN: TOTAL STANDBY TIME �1 D NEAREST O FAMILY ID TRANSFER WAIT TIME T D PATIENT .•❑ DIRECT O OTHER.: (� CALL BACK N: AMBULANCE COMPANY:j, PT.AMBULATORY? PATENT TAKEN TO AMBULANCE :` RESPONSE ZONE r ?f D YES D NO D WALKED (7 GUFRNE-Y D OTHER r - ' ,I: PATIENTbONDITION: DRIVER �FMT-�A TECHNICIAN �X PARAMEDIC �+#*' c,`.` f . Hx:.l"; }� :1�.'�_1 t I 1 f,t, r•nff DISPATCHER: CHIEF COMPLAINT: `.- '! i. t ' : {i• ') . DRY RUN: DYES O NO REASON FOR DRY RUN `e"i is`'`';.:• AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES: (SIGNATURE) X 1 r �- ll.., .. MEDICAL COVERAGE: _ INDUSTRIAL ❑ YES b NO NO.OF PATIENTS: :- PRIVATE INS.CO.: BASE RATE: 4s'UL �} t KAISER N: � , MULTIPLE PTS.BASE RATE � + '. jr; BLUE GROSS N; , - TOTAL MILES:-.-_ L'L X y � •• �. a:;F•ta' MEDICARE N: - i•1- ;.-_E.O.B.ATT. ROUND TRIP: O YES D NO •;:.-)< ,:.:• D YES1 NO NIGHT:(19'00-07:00) }... .! a pr. ..�.�'. .'.'i' t CCHP/PPRP N: EMERGENCY RUN: al+- In MEDI-CAL N:—_� CODE 2/0 OTHER:—__.-..____�. OXYGEN: (PER TANK) P.O.E.STICKER O YES 11 NO NEONATAL_' (INCUBATOR) DATES BILLED:� .t.c�•y -�3�c - STANDBY: (OVER 15 MIN.) .';• le[. E.K.G.: (PER EPISODE) 1, ' NEAREST RELATIVE/RESPONSIBLE PARTY I.V: (PER AnM1t11___-.. X D°TUGS: ( rIl ACt.IIN).__ X. NAME:_-_.. � � RELATIUN,SHIF':J.lL0'L E t}A.: (IF NOT REPLACED) _.•Lr•a �: ADDRESS: _.._ ORAL AIRWAY: (IF NOT REPLACED) T� CITY: __ STATE._—ZIP C-COLLAR. (IF NOT REPLACED) PHONE: _ WORK PHONE DRY RUN: (AUTHORIZED) r EMPLOYER: OCCUPAT ION: OTHER: ADDRESS: ---- - ----- — --- 5 - CITY: STATE:._._.ZIP _ _ i r ! COMMENTS:—---- --- RE.CLIV_EU ........ --- •4in'L*.+�,i. V 16-1 ' TOTAL:-.. .s5.�S.__ CA{.)ILLAL't1f{iRULNYCE_ PATIENT REGF.rvF.D BY: X (SIGNATURE) -�:• rf •.•;{rr rr tn:. Vhi4 •re. r••vl ['t'y Rrluir: r•li.c .�•p :�^ }•:Ter:. W-1.;C , LiLMAND NO. 229 VI Ih0n 0 A 1, [6, "it file 1rr;l%llI% of file ?I ('()(!N l\ 01: ('()N I R:% ('()S'I ,% Presented By: SIA11: OF CALIFORNIA DATE 6-28-82 CADILLAC AHBULANCE SERVICE, 111C. "I NAME It AISIVORI ANT 4601 NEVIN AVENUE tier ln%lructions nn Reverse Side 4 ADDRESS j1CH1-1QNDj CA 94805 CONTRACT # 22-079-8 CITY. $TAT[ zip CODE DATE: 7-1-81t0 6-30-82 I 17� T For the sum of***ONE THOUSAND EIGHT HUNDRED* FORTY SEVEN AND 35/100**** Dollars $ 11847.35 As itemrjed beloo : ' UNCOLLECTIBLES DATE DESCRIPTION AMOUNT d ............ SEE ATTACHED PAGES L .5 .2432.55 .2/34/4/j) 4f- -m4 `TO-1 CLP9 KL'Utl "B-) AUG 'I'lle tind-Isi-11cd IIIII)f!1 Ow (11 j-i%tjIIrY stateg : 'I'llat the above claim and the jjr-jils as therein se%out are true and CorfeCt-. i lijat no pit ilwrvof has Imi-vtolmi, vai(], and that the amount therein is justly-wil.1/and that theSaMeis presented within one, eat after the last Item thea-1,1 has accrund. F Signed ,Cep P e c e i v e d, Accepted , o n d Expenditure Aulhowed p, T M I my—HE'AD -c-".ItIr PC PUT T cc Ouk Uld a To N 60 OU147 u6 . . . . . . . . . . . . . . . --071d T itI-a rib; ACTIVITY 11110 FL43 I DISCOVMT FFFM1 I p -V4 NO INVO'ci ;—AT! VILICS"750% tv"D/0"s ACCOUNT COCUSSMANCI NO. P/C l PAYMENT AMOUNT it f-.1TA 91. •AMOUNT TAilo"PT10% ACTIVITY I I T PUNIC/04 I C E--OV-11 7 NWNSRANCE No C p VNIMI AMOUNT UW F 165: TANAILL AMOUNFAi �orTION� ACTIVITY -1c fteg1 ID15 pe. '�X 41 _ 1) • . _ __ _ b qtr PRE IIOSIPITAL CtiF1EAMBULANCE • :?. 1 ;{ FORM ) UNIT AUTHORIZATION N p CHECK OR illL IN APPpOPq/A1C SPACES , DATE: O M ,O,F COMPANY IIWj ADORESS'�J.4____2W4 Alf6n - AGE ) ?( J• CITY L'/f C� LUSf�� _ STATE :T� ZIP -7 Tri m 008 1p '1 S')O Sn O M O T f]W;O Th.)IF.:Q S 51 E AAS . '' DRIVER'S LICENSE N _. _._.__--- PHONE NATURE OF DISPATCH � TYPE OF TRANSPORT: AMBULANCE 0.OTHER O _ {V"k INCIDENT LOCATION: I RESPONSE CODE: REOUESTED BY: TIME-(24 HOUR CLOCK) i ? 1�'�'► ,� -.?QS. ' TO SCENE- D S.O. CALL RECEIVED S ` Z DL O P.D. TIME 10.8 PATI EAIT"LSESTINATION: ` FROM SCENE- D FIRE TIME 10.97 1 IL r1 f 'j O PSAP TIME 10.49 ` - -�- MILEAGE- O OTHER/PVT ' TIME 10.7 END ?r `� 1)i'1 TIME 10-98 DOCTOR " PMD/ER START -� TIME 1422y Ct105EN;` TOTAL i 1%f': 1• .':;•,:•:N: STANDBY TIME I• i + .... NEAREST - D FAMILY ❑ TRANSFER WAIT TIME ) O PATIENT D DIRECT O OTHER I ?/ CALL BACK N: AMBULANCE COMPANY PT.AMBULATORY?. PATIENT TAKEN TO AMBULANCE: '. RESPONSE ZON ,x O YES h NO D WALKED O GUERNEY O OTHER 1� �V l r i•: ' r" '♦� PATIENT CONDITION: DRIVER 1 1 i 1�. ? EMT-IA l TECHNICIAN I / PARAMEDIC i l ': ( I,! C L>1!i/' trA)S" d icJ/t/ I f 4 Hx: � % DISPATCHER: _{ k!l%'x :CHIEF COMPLAINT: ,/ 1 L + I'i �'1/�ISL' f DRY RUN: O YES I,O NO REASON FOR DRY RUN �S ' ; i. .� •. AUTHORIZATION FOR DRY RUN(EMS USE ONLY) �F PATIENT REFUSED SERVICES:(SIGNATURE) X_ y1 - MEDICAL COVERAGE: INDUSTRIAL O YES,� NO NO.OF.PATIENTS: ° .fY i/r;j 'i �':.y*y.''• S.S.N�. I.w ,5 ..f.+ �.'� Y` t Fh. S ,`; t •:i k.7k. PRIVATE INS.CO.: BASE RATE: :SAL..3 r. rt.KA1SER M: MULTIPLE PTS.BASE RATE BLUE CROSS N: TOTAL MILES: z{_X ' r. MEDICARE N: E.O.B. ATT. ROUND TRIP: ❑ YES D NO 'i�•`,` : - O YES ONO NIGHT:(19:00-07:00) - -: ' 6 CCHP/PPRP N: EMERGENCY RUN: A•7o °' MEDI-CAL N: __ CODE2/3 .:�'..' `^`�:.f:p OTHER:--___._..___- _- OXYGEN: (PER TANK) P.O.E. STICKER D YES D NO NEONATAL: (INCUBATOR) , DATES BILLED:.?2 � (.-Lf..-J'11 STANDBY: (OVER 15 MIN.) .i/SL�t_�yy`�S'�D(.Y•' E.K.G.: (PER EPISODE) + r NEAREST RELATIVE/RESPONSIBLE PARTY: I.V: (PER ADMIN.) - .- X °t DRUGS: (PER ADMIN.)-. X � '• NAME:__ .____ ._.__ RELATIONSHIP: E.O.A.: (IF NOT REPLACED) ADDRESS: _,_.__-_..--___-..__- ORAL AIRWAY: (IF NOT REPLACED) x' , CITY: _. STATE--.-ZIP: C-COLLAR: (IF NOT REPLACED) 7 � , PHONE: WORK PHONE'- _..^ DRY RUN:.(AUTHORIZED) W. I + EMPLOYER: _ OCCUPATION: OTHER; :'-`;,:''• ADDRESS: CITY: ---.._- STATE:---._--ZIP: ,.COMMENTS: --- —RE!;EIVEU._.._ y5 TOTAL:—J.. :— . ..LG._SS r CADILLAC AMBULANCE -_. PATIENT RECEIVED BY:X ! %`�-J •'•�'i; , ._"... ..._. ___ _. ........ .. ..__�_ f7• (SIGNATURE) p 1'n. i ier Iw': t5:r• z.:.J o-:,.; ;, Frtarn,I�Iir: m1. ro ' •:Orn f�. '•:i Of!-1 ;',1�iL: • 'I • _ • DEMAND N0. 233 I)I:A1 t14t .0 VINIIOR NO Air. ?; J 16,01 01 01 3] �., on Ilse -I�rrawn• is( Ilse . ('01 IN I Y (tI' ('It\ I V-1, ('(IS I : is r3resented Ry: SI A I li til; ('Al.11'I IHN1A DATE 6-30-82 - CADILLAC AI.IBULANCE_ _SE_RVICE_,,_ INC_ NCM[ ItAI,i- - -- - -- n�Nen III ANT ! 4601 NEVIN AVENUE C,•e IMIfUr,lln115 on Reverse Sidi ^ ADDI[39 --- -- _ a� RICHL10ND2 CA 94805 CONTRACT' # 22-079-8 t( CITT, STATE— ZIP COD[ DATE: 7-1-81 t06-30-82 �— :j For the sum of *******ONE_THOUSAND SIX HUNDRED NINETY FOUR AND 25/100***Donors =1.694.25 ': ` _ _ _ - As itemized below: PHP MEMBERS • DATE DESCRIPTION — AMOUNT RE UE © —!S ACHED Emergency enc Medi al Services - 6, l �r -- -- --- ---- --- - PAGES —_r_nrYgf®riar��. , 6r,Crge-cy LicCicai Services -- — d(.L.._ZAPZiI7'�n'9/-/1�G/l_nrr4d� T_----- . IIII .� ',��• -R .CEPAED - f . ..... ---------- ---- _.._.. -- - CA[A LLA The und,•rsicru•d undl•1 r!1 pr•nalr\ (if perinr} states: Thal thn ai)ove claim and rhe it••ms as therein set out are true and correct; 'hat no pall llww if has b••rn her•-loluil• paid, and that the anrount therein is pstlp dm� and that the samti is presented within one . tear after the las[ item rh(-r 'nl has accrued. c / Signed � Jam. >/�t_�I,L-' �•.7cc.,rr.� VENDOR NO. Received, Accepted , and Elpenditure Authorized 4::_::�_ :I PPNTNCM t,w I iJ'Dw` MILD OCP •''TTS-- - JrU7_7£[ LIf[� 6[TC[r1T1lF //11111,/1/6%011 ACCOUNT turi ifi7Zi2T NO F] PAYMENT AMOUNT �II CIIW U f � ( RfiVM ACTIVITY 11PIC FLI12T DISCOUNT ' , suY. ro INrcict o[1[ Ot iCKIPTION r�01i IeCOUNT UICVr/NCMC[ N0. �r/C , PATIO94T •MOVNi 1 , 1 •TAI CIC ArOUNT TAIe DIiIDN ACTITITT DISCOUNT , IUIO NO INY01� DIT[ �� OC ICN11T104 FUND/DPI ACCOUNT S%Cur IIAMCC NO P/C ( PATrtNTIrCN-T- •—JJ—. l/tl All[ AYCUIIT TCI• D.r IOM ACI Is,ITT LCICO /LI7 I DIICOVN (OIs P.. '/T 7) r------- 1 t14 C ; •`•4. CONT(IA COSTA f:f+ s:J i tif)nr1 ri,I. 1't,S1f: F0)1FA 1 nrtrt AUTHORIZATION N�___ r ...rr.rnil.ullwerrnnrm.rr:re.:rc DATE: 'r Tr��?- - ------ OM MF COMPANY ..:.,y.M •'t U t Af,l„•,. :i 'T S[1(h�MYD� r ---- :_. _ AGF. 1.'._—. ZIP _._Lit�S�'r DOB._!'.i =:1 OSn 'OM .� T .OWi'�.ThrO.F• 0.$. c . .� t vrr,,t 11's I.Ir.rJJ%F tl _`..-.... _ ---_: : PHONE_LL=.�l�is�_._.__. NATURE OF DISPATCH , I Y1•F It!1' t IThNFPf1R T• Al 1111 ILANCE Tl OTHER L.) •. __ r :; +rf 9 1Yµ i *r '�� * . ilk. 1 .. ;.:, ,"• ' ?• .l.a .� � ��a . RJ6(17.fJ rIl O/ AT t()N RESPONSE CODE RC:Ol1ESTED BY. TIME—(24 HOUR C TO SCENE- O S.O.T__ CALL RECEIVED 13 PD. TIME 10.8 �' -J—L`• • jxf PAI , rl : FROM SCENE- O FIRE TIME 19.97 O PSAP TIME 10-49 ::�C'•� CJ.�f '•' _ I1�r.1_1r�: 1:_ ILEAGE: O I THIR/P%D TIME 10.7 ( END r 7, .; TIME 10-98 START _) TIME 10-22 ' r1"HOW CHOSEN. NOTAL ^LZ.”"" STANDBY TIME f I ► �; . v NFAW7.s'r. 11 FAMILY EI TRANSFE ' WAIT TIME ' - fl 0 PATIENT In DIRECT O OTHER CALL BACK is AMBULANG O IY- •,} i - ' y , PT A1,IBULT(TOR'%?. PATitUT TAKEN TO AMBULANCE! RESPONSE ZONE ' v �" i O VFS Lti NO O WAI.KED O GUERNF_Y O OTHER (f, l zTx�i' P• (`�PdI .,t PATIENT CONOIT ION : DRIVER___T idt _ __CEMT-lA 1 S; TECHNICIANS' )' " d 1• ___T—PARAMEDIC r ;• •moi f .l q + _. � � �t•• —�t�.•__ __ __ -:'G •l.iA`" 1. DISPATCHER: -L CF11EF COMPLAINT: __T+...!•r_L'.s?�__-1L._ �� DRY PI IN: O YES M NO REASON FOR DRY RUN roti, AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENr REFUSED SERVICES,(SIGNATURE)X �,Y • ul s MEDICAL COVERAGE; INDUSTRIAL O YES 0 NO NO. OF PATIENTS: r - ,S.S.M �`n'?=—::t_C.---'�1-'�----- t r�l'y+5` A PRIVATE INS CO.'.— ._.____— BASE RATE. KAIREq a . — MULTIPLE PTS.'BASE RATE (VU1F CROSS N)_— .. .__.._ ___ ..— TOTAL MILES: X .2.ko , •f u"ti� MEDICARE N:. ' __—E.O.B. ATT. ROUND TRIP: O YES O NO O YES ONO NIGHT: (19:00-07:00) �• •GC11P ('PHP a: 0..7r 3 vr. 021.97.3.Y_U_o./.— EMERGENCY RUN: h1_ TI•I:.1L a: CODE 2/3 3 s OXYGEN: (PER TANK) P o F .f:rl(-KVFI CI YE. ❑ NO NEONATAL: (INCUBATOR) DATE'1MLLEU _ . . ------...-._—.'.—'—_...._ — STANDBY (OVER 15 MIN.) ELK G.' (PER EPISODE) NEATIr;T RFI_ATIVI:.IIF';PON51R1 E PARTY: I.V (PER ADMIN) ...__.—._____X -__.—_ •.. '�'. DRUGS: (PER Ar)MIN 1 __. X e�� 1.J.�4tL / ::•_. _._ RELATIONSHIP: EO A.: (IF NOT REPLACED _..._. .__ - ) ..._ ORAL AIRWAY (IF NOT REPLACED) r;11Y STATE._ .—.ZIP: C-COLLAR: IIF NOT REPLACED) ' $. ...... ._ :. pllyd _ .. _ __ .__._,.. VlORK PHOr1F ____._.. ____ DRY RIJN: (AUTHORIZED) E f.IPl. ern.f.."._.1.: .. CCCUPA TIOIJ ..=-- OTHER: ADDRESS: CITY. ,•�_: _.a_. . . STAIF r AUIJ 168. ,; ,.• , CAMLLAC AtIBULAiiCL i PA 1ENT RF r-r✓r.r,li'I X ..... _. . _-- _ ___; ,,•;il�;°_� • - I � •..� _. f i•.' • - UL11Af4 U NU. 227 Diehl %NJ) '' • � VI ❑I+OR NO c A G Il) U U (1...3 L� • "ITT the Ttrnws.y of the "'� � � + %'. - C(1UN71' 01; ('0N*I 16% COSI A Presented ey: SIA7EOFCAI-IFOItNIA DATE 6-28-82 f CE1pi11nc_�[_�C.ulnrac�_sF�rr�.ct ,_ rric., MANI (LUT) 1- IMPORTANT �D � �LMDE See instructions on Reverse Side $]CHr_1Q P, CA 94805 C014IRACT # 22-079-8 CITY, STALL I11 CODE DATE: 7-1-81 to 6-30-82 L I I 1 1 L I 777-71 J.4 For the sum of ******ONE THOUSAND NINE HUNDRED NINETY TWO AND 201100*** oltarf = 1,992.20 . .'a. .�+ ;i;-, As itemized below: UNCOLLECTIBLES :..t,'t .: DATE DESCRIPTION AMOUNT T-nR�h'AahFI? •' SEE ATTACHED 20 PAGES AddL � l]11112 ;/ .? fiD (,/ UA ECEIVE RECEIVED ,utv tAedica{Sc(vtce� E3ULANCE: EmetgencY .,�:.� The undersigned under the penalty of perjury states: That the above claim and the items as therein set out are true and correct; uat no part thereof has been beretufurc paid, and that the amount therein is jnstI du , and that ti) a e is presented within one •sar after the last itern thereof has accrued, r! � Signed VENDOR No. Received, Accepted , and EFpendlture Authorized /A 'i ' - " •• I ` �— �i•.ANTMIMT MC AO 0A••CMILI-QGV7T "vSf iiS iLi L1TTr "- " "1i12T 1TiL 11157ZA1 —1-C T T�MilirlRT Mme. c I /M M •M ul 31 l � / T 'i F -60TIOM L rl,. L.IL /143. DISCOUNTTITTn ' 1 'ult. ■0. IIIYOICI DATI OI ICiIF T 10 0 —uM�Oi[. -•CCOYA• I[CYM/[AMCI NO. P/C I/TMIMT AMOUNT . • T�1+•{l •MOV IIT T//c OITW■ ACTIVITY DISCOUNT nm I t ' . 1 MGN ITT–IOM— FUND OA/ ACCOUNT /NCYMIItANCI MO P/C ' PAYMENT AMOUNT . �_ 1691 .:. fAl Atll AYOYNT TAI[ 7ITIDN ACTIVITY IIPIC FL93.1 DISCOUNT (DIe Rev 7/77) FFM l , CONT&OSTA COUNTY �ti AMF31Jl�1RCE ~• y )?��; t PRE-HOSPITAL CARE FORM 1 UNIT (�'� AUTHORIZATION N .,.�1ill 7 i i I I 1 ! w .,:.!`•,�dr ,Y+ 1 Cift cx Dottie IN AI PAI)PRIATE SPACES � DATE:...__mac � •' � '��� tiai ti.•p PATIENT'S NAME(J_��.L _-, jr 1��" .._.. f _.— .�ItrM _u COMPANY N tt 1 ..t ,3l_� .l 1__�11;Jt.�,L. �JG• i � 1Oev ADDRESS _u__ ,t__ _ `AGEi._� 'STATE —!�' ZIP `_�_��1 ��-� i DOB�L�—t: D Sere D M D T D W D 7►1,� �3= • DRIVER'S LICENSE a — _ PHON41Y o 8 ll_ NATURE OF DISPATCH�� I rll1 LI t.�jt�.y '+ TYPE OF TRANSPORT: .AMBULANCE,O OTHER 0 INCIDENT LOCATION: RESPONSE CODE: 1 REQUESTED BY: TIME—(24 HOUR CLO K)4t 1 TO SCENE= O S.O. CALL RECEIVED.: J Y` P+` at.'-.. /).. \�_ t•� 11 .71r`•�) 1( / _ _ OP.D. TIME 108 t j ' Y-PAT DESTINATION. FROM SCENE- D FIRE TIME + ' \ O PSAP.___ _ TIME 10-49_ f V, ) RrFW,' TIME 10-7 : MILEACaE: .{ '� 071•tE - s 7 I. _-- �. J i .t END(- q TIME 10 DOCTOR __'..:_'.t t".t���--FpAD)ER STAFITJ' r'— �j�Lc1 TIME 10-22 i ) S ' HOW CHOSEN: TOTAL ���Y� _ '•- r�� STANDBY TIME s. ? D NEAREST .7 FAMILY D TRAN. Fr — WAIT TIME ' D PATIENT -`-0 DIRECT D OTHER \�) CALL BACK N� AMBULANCE O Y -� , f4, RT:AMBULATORY? PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE t t D:YES D NO D WALKED A GUERyE-Y D OTHER _ PATIENT CONDITION: DRIVER +•.(+ F�MT-��_ J •� ! ' :TECHNICIAN ;�` PARAMEDIC ti s Hx: — —�.__T_ DISPATCHER: k(.. ;Y . r l:. 1 UA.1 1)1) �. y� CHIEF COMPLAINT: , DRY RUN: ❑ YES r,I] NO REASON FOR DRY RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLYJ PATIENT REFUSED SERVICES:(SIGNATURE) X + j MEDICAL COVERAGE: 7 > r ,,• ' r 1 1 US 4l D YEQ��INO NO.OF PATIENTS: '' ` .. I�YJ S.S. I LA, .. t. \._ c to PRIVATE INS.CO.: r BASE RATE:MAI mkllr.-.n �i;4 +. KAISER N: _ MULTIPLE PTS.BASE RATE + d + I#+'YI� BLUE CROSS N:_.:",'{}—� TOTAL MILES: X �.1 MEDICARE N: "L I ' E.O.B. ATT. ROUND TRIP: D YES D NO c Xt �'i k: � 3•,�� ),IC:rp(i1ry MOf.Iral;: -. D YES�OZJO NIGHT: (19:00-07:00) .. .. E' (' CCHP/PPHPN:_� EMERGENCY RUN: jc• CMEDI-CAL p1---- 1j—=- I CODE 2/3 l '::,'t:; • OTHER:---------- ----- OXYGEN: (PER TANK) �+70 P.O.E. STICKER O YES ONO NEONATAL: (INCUBATOR) __� K "`,•.;;".: - , DATES BILLED:_.�_1"L•"_i4�Li .moi=/'1'.-.F.L- - STANDBY: (OVER 15 MIN.) _ ,' {.1 •i v . E K.G.: (PER EPISODE) NEAREST RELATIVE.RESPONSIBLE PART'(. I V,: (PER ADMIN.).- 'X '.:. ; =DRUGS: (PER ADMIN.). X NAME:,---l-� �-.�_ ._—(___��•I REIATIONSHIYI'It% �'t`•( E.O.A.:(IF NOT REPLACED) ,—� •'? tic ADDRESS:—_— _— __—'_�___._,__......__.__ ORAL AIRWAY. (IF NOT REPLACED) CITY: .. - __— — STATF—__ZIP: C-COLLAR: (IF NOT REPLACED) PHONE: - _ WORK FI!ONE:._.___— DRY RUN: (AUTHORIZED) '% EMPLOYER: — OCCUPATION: OTHER: -.',. ADDRESS:---- ---- ----- — ---- ,,a ; i CITY: ___ —_ STATE:. ._ZIP. — —� RLCUIVEp COMMENTS: .._ ..— -- ---- ----— — —-- ? AUG -- - -- - — TOTAL:__.. '� ---•- - --- -- --_. .--W!LLAC AMGULAhI+r=- ' -;- ". _.......... . ... - -.._ F _ PATIENT7 RECEIVED BY:X u ..:�:r- .. .(SI�NAT RE) •ti ry; •or+: i': :4-. '!:i' :1 OIS 1 *•. DEMAND NO. 247 ` —' • I) NIANI) • VENnOn No Art. r TxT u1r 'ftca.nn• of the .a 4. o [.(I UOt IN I Y OF CON I RA COS rn =; Presented By: STATE{011-' ('AlIIORNIA DATE 7-26-82 ;. CADILLAC IU•IL'tll_ANCE SLRVICE,- 111C. NAY[ Il Aftl —_------1r INAl) � IMPORTANT 4601 NEVIN AVENUE Scc lnstruclinns nn Reverse Side AODtt!! _ RICHMOND, CA 94805 CONTRACT # 22-079-8 >s. CITY, ITATt !IP CODE - DATE: 7-1-81 to 6-30-82 �• c:i For the sum of *****SIX HUNDRED EI,GHJY FOUR AND 90/100**************** Donors $684.90 As itemized below: PARAMEDIC DATE DESCRIPT(ON AMOUNT M• wy, SEE ATTACHED 4• -- -------- -- ----- -- -- RECEIVED PAGES Emeigt:�7 RECEIVED AUG1 •+\1 o I�ts� ADILLAC AMBULANCE The. undersigned undCr I1i1' pl>Iiall6 of per.ptn• statrs: •I"fiat the above claim and the items as therein set Out are true and Correct; Ihat no parr thereof has b1•I•n hrsetnfole paid, and that the amount therein is justly--d i, and that the Same is presented within one.: •ear after the last item thereof has accrued. Signed 2UZi ryx• rcn�� VENDOR NO. Received, Ti — - Accepted., and Expenditure Authorized Di A" Y[Yt x[AD 011 CHIEF DEPUTY i 1v� Ta 7, VfT 6CR 1►riSF T 7-o>I ACC—cuTT NCUM94AR No • c • TatioT Au0UkT 1� %61 , 1 1 'Tfilfi 7Y3GrT— T o�a3rACIJVIYT leetc cul. , DucouN r . FTMr sur. ■0. Irr01[l DATt 0t A CC A IP 110 it P un D/at E. AC C OWNS ancuYttANct 00. PIC PAYMENT AMOUNT - — 1 lAl A1L Ar 0Yt7 toIN Wnox •tllrnt Oleco�e et/[ell11Om /�DA[ ACCOUNT IMG VY ItA NCI NO PIC I PArYt rT AMOUNT • �I TA'x Allt uAt AMOUNT 1 T . or hO+l ImI. t•tC rkt) DISCOUNT 1 r 1 CONTRA COSTA COUNTY PRE-HOSPLTAL RE REPORT , t DISPATCH INFORMATION' TIME (24 HOUR CLOCK) MILEAGE CAII Received: End NATURE OF PRO13LEM '`f , ' � ' 18sdispatchaf) _ ��'t' Time 10.8 Start-- INCIDENT tart INCIDENT LOCATIONTime 10 17 Total .Address 'r� !f�.�._ Time 1049 Li :'1/ RESPONSE CODE ''!i 'N City: Fr Cross St.: Time 10.7 To scene 3 / r y' i. 15, 't ?Call Back No.: - (! < ' _ . , : Time 10.98 _ u. •) f'd' r y Requested By: `�'(S.O.❑P.D.D Fire D PSAP Time 10.22 } From scene yOther/PVT Standby Time / / +r� . • EPATIENT DESTINATIONAj' Wait Time fO �� C• Cancelled By How Chosen: i x a ''. DryRun: ❑Yes ❑No•. : ,,i< ri. ❑Nearest ❑Family OTransfer Reason for Dry Run isiR dCl a [, .:r Patient ❑Direct Admit []Other Authorization for Dry Run IEMS Use Only)' " . t PATIENT/BILLING INFORMATION . ' EMT-IA Unit No. 7 , y Parem_edic Unit No.- ? •1}l�k e Patient's Name: _ 143a �� � ir) ec, r i,,r Oriver'-- ✓ 1:4 r-.s�'.r ts� :0W,1 - ' Attendant f a AIR Address: WF D.O.B.: ! Age:— Dispatcher ''�I.r' �.. i�( /� J '�sl>pt'•' • 4 { bLU!s i+� Type of Transport: dmbulanc�/VVheeicha❑/Cer y' Address• ���� .,k �N�.. ( Ambulance Company: I City: r State: Zip: illi ❑Antioch ❑Morelia Fire RESPONSE ZONE ©Cadillac ❑Pomeroy cj�1 ❑2 ..❑3 •❑4 Phone: ` iS tS l Z�� S.S.No.: i 11 East C.C. ❑l'ri-Cities 05:';06 117 .❑B Occupation: ' : .. •� ❑Michael's ❑Valley Fire 139. 010 •;:..'�j, ' PL'Seen,by PMD. M.D. +' : llil.Other Physician:110� I �'_ •• % ' } M D.'. !.e •:� �r'!a t 4� 6 f\" r' RESPONSIBLE PARTY31 ��',. •I ri} +-+.: - .. `'Stg n Base Rate: It pt.) i Air, F+r t 41 of 2 pts.) ¢ •{�. ❑ »� c ^ Relationship: (t of 3 pts.) c Address: Total Miles X4+ I ,' i .T `.❑ Z. City: State: Zip: Round Trip o:, . ❑Yes D No t E, .. .A Phone: Occupation: Night(7:00 p.m.•7:00 a.m.) ;:❑ '.( t:+s Work Phone: Employer: Emergency Run {: ? of Address: Code 2 oQ� 'Cade 3 City: State: Zip: Oxygen(Per Tank) ., Neonatal(incubator) + .•. Y t MEDICAL COVERAGE INDUSTRIAL DYes 13 No //uru ' El 11 Standby lover 15 min.) m Private Ins.Co.: EKG(per episode) _ . • I.V.(per admin.)._LX /i,no- - /t nn � » 71 ` Kaiser No.: Drugs(per admin,) ;A.•'� nnC _ R2- nn ;A. Blue Cr ss No": EOA(if not replaced) Y.,;: t. Oral Airway(If not replaced) �•�fr� lY Medicare. No.: E.O.M.B.Attached C-Collar(if not replaced) " � �' 1! j; ❑Yes ONo . . ..y� � , Ory Run(authorized) �'.•< )':r�' - l` 'CCHP No.: : ,,^^`` Other: RrrrIVED POE Sticker ' ❑Yes D Nn A(l(l I •� •ti t - A Dates Billed: --- - _. Total: AMBUTAtJC_ . 172, i DEMAND NU. 241 NO A Ar ba I) ()F (IN I V�% ('()S 1 .% 'Presented BY: S 1*A IF Of-' CAIJ 1-IMNI A DATE 7-8-82 CAD I LLA.C_ IRC NAME it Aq 11 1.In q I I IMPORIANT 46-ULBLUILAYUM Scc hi%tructi,mI; nn Reverse Side ADDRESS, RIQUIOND. CA 94805 CONTRACT # 22-079-8 CITY. STAY t .10, coot DATE: 7-1-81 to 6-30-82 For the Sum of _ONE THOUSAND TWENTY EIGHT AND 35/100*********** Dollars $1,028-35 it .As itemized below: UNCOLLECTIBLES REBILLING DATE DESCRIPTION AMOUNT ri I vc-C) SEE ATTACHED • PAGES --PLEASE.NOTE:_ Copies of our statements attached. #_-�W Ovd l;444, .4.4 rL x i:W_16hW RECEIVED 7---- ------- CIA[IL 1BULMC-1-- _Z: The nnrlerslt m d unfl,,r oin pf-jialt.v of lietilirY states: That the ahove 0aim and Ilip,items as therein set out are true and corfe( Ihat no Part Ihvt-,ot has hiIi•n hei,!1oforf- Paid• and that the amount therein is jiistly,iluiy: and that the wine is presented within one vear after ilin last iti-ni t1wroof has ;IlTriwd. siglit'll r low I Rect;%Pd I Accepted, and Espendilure Authorized HEAD Or colt.r DEPUTY k V C PATWENT AMOUNT Ilii J TE, 611TIF" C 1viTv DISCOUNT 4". no 1-N—V0ICE—eirt DI ICMrTtCe FUND/coo ACCCVRT ENCUMBRANCE NO. P/C PAYMENT ANQUI111 L L fie- Aty Aiiiiii— *i iii-14641;-1,0"I ACTIVITY 0111COUNT rM Num no Acizil" "CTW§1kA%C9 NO P/C PAYMENT Tall' TA[Acle *iau 4 T I'Aiii' &FiF_,Ci ic-7 I v—If 17C DISCOUk 7 CONTRA CCOUNTY r Af40UL. �E-HOSPITA�ARE FORM I UNIT. 7 r' AUTHORIZATION N 6 I CLI � -+ ,.;kOAnLLfNArpoor ATESOACFS DATE: ► { 4 - � ' 7rr s i I T fENI'SNAME�_�LI-L ► I �:�_.{1,J-�y.------- M O-F COMPANY .ft _ i. ;. _ y ' +t ADO ESS SJ, 1 -__/ t.I: l i)s<_:— AG-E\I \ 1� ,�V IVIJ t STATE r-�1�-- ZIP DOR1L LTJ 1� 0 Sn ,qM O T ❑W ❑ OF ❑S : y ' +e '. CITY_ _._� -_ Th '•f �'' DRIVER'S l ICENSE N PHONE__.— . NATURE OF DISPATCH \ - - , TYPE OF TRANSPORT: AMBULANCE OTHER 11 3 INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME— HOUR CLOCK) _ 'rk• r S )) TO SCENE- O S.O.. CALL RECEIVED » + 1 1 I 1 �• I`, ❑ P.D. TIME 10-8 -' {:'" PATIENT DESTINATION: ` FROM SCENE-�/^ 13 CIRE TIME 10.97 PSAP TIME 10-49 ,i MILEAGE: t7 r� ,R OTHFR/PVT TIME 10-7 END O . TIME 10.98 Q� a +1 E DOCTOR -x L:. i,i r.� I - „ PMD/ER STAR �' l L TIME 10.22 1 1�+ 14 : HOW CHOSEN: \ TOTAL �trz,T'N T� /,i�-- STANDBY TIME =F'';• ❑ NEAREST ❑ FAMILY WAIT TIME ' J - ❑ PATIENT ❑ DIRECT, 'f7 OTHER CALL BACK N: AMBULANCE COMPANY: + I 91�T _. it �t3 �`. . PT.AMBULATORY? PATIEN�-TAKEN TO AMBULANCE: RESPONSE ZONE Z ..� 0 YES ❑ NO CI WALKED ❑ GUERNFY O OTHER — YI J, PATIENT CONDITION: DRIVER LID-11— 7 -7 (�EMT-iF✓ ✓` i t r. ' TECHNICIAN ') ( .) /_ ! I PARAMEDIC 4tk �+ ,c Hx: ,- DISPATCHER: €a 1CHIEF COMPLAINT. _) • = 1 . 1 C �'� r(�)-f7-- a�RY�pp�((uu EE S (� NO REASON FOR DRY RUN 3 AUTO I I N FOA DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES:(SIGNATURE)X-MAX--2 04982 ti MEDICAL COVERAGE: INDUSTRIAL ❑ YE. ���•}(`����{ N M p T E �IlV lea. V711YI�U�IIIi L' - S.S. yti: >, PRIVATE INS.,CO.: BASE RATE: .? f j-, �' KAISER N: MULTIPLE PTS.BASE RATE s fy BLUE CROSS N: TOTAL MILES: _._—.__�X ,r'' do % .25'20 MEDICARE N: _ E.O.B. ATT. ROUND TRIP: ❑ YES ❑ NO 70 w•yp • I( O VES .Q NO NICHT: (19:00-07:00) q. 00 CCHP/PPHPN: -- — EMERGENCY RUN: MEDT-CAL N: CODE 2 1 3 f; ' OTHER:-----. �.:. OXYGEN: (PER TANK) ,?` P.O.E. STICKER ❑ YES Cl NO NEONATAL! (INCUBATOR) lei ' ` C>I-o1 (_` L"-- . !;. � DATES BILLED: �� L�} �� °'+�� STANDBY: (OVER Ifi MIN.) )]! E.K.G.: (PER EPISODE) rl, NEAREST RELATIVE/RESPONSIBLE PARTY, IV. (PER ADMIN) X .'4 � DR'IGS: (PER ADMIN.(- - X ` r NAME:—;• I�._�_._ RELATIONSHIP:.._..___.. E.0 A.: (IF NOT REPLACED) ADDRESS: ORAL AIRWAY. (IF NOT REPLACED) " ,.t. CITY _ —..... STATE._.—_ZIP:_—. C-COLLAR: OF NOT REPLACED) PHONE: ._ ...�__ WORK PHO`JE:...— DRY RUN: (AUTHORIZED) . :• +:(, EMPLOYER: --. _ OCCUPATION _._ OTHER: ADDRESS: CITY: --- ---- STATE:-----ZIP:—, ----= �vr•n COMMENTS:._ e 7 i' J .. ..--- - - - ------- T OIAL.— 11 .:( ... * _ U� J. �..I •u , PATIENT RLC°IVFD RY: X. _—_._--__... 1" f+:r n...�+.�1}I(_I:^•(. ,DLII%t'I_Af••.,� 1':11-.v _. .. ,..: .. (SIGNATURE) 4.: JIIIIIA COS IA COIINIY AMI111l.ANCE ' HOSPI* CARE FORM 1 — uNrrtW AUTHORIZATION M ..tat ON•nrnnrnure sneers DATE: . .T ,r9 'S NAME b M ❑ F COMPANY M_l f-:) ��•' ' DRESS x. AGE !`CITU 1 STATE_ - ZIP DOB . . O Sn ❑ M O T O W O Th' O F'•O S. , ,ttik '. I DRIVER'S LICENSE p PHONE NATURE OF DISPATCH-;v,", _f ! ; TYPE OF TRANSPORT: AMBULANCE D OTHER O t��•. INCIDENT LOCATION+ RESPONSE CODE: ! REOUESTED BY: TIME- (24 HOUR CLOCK) TO SCENE- 7 O S.O. CALL RECEIVED _ P.D. TIME 10-8 .i :}=PATIENT-DESTINATION: FROM SCENE-_ O FIRE TIME 1097 O PSAP, TIME 10-49 :r: `� MILE GE' r r xQ,QTHEk/PVT TIME 10.7 . . . 0 7 l 1 -f TIME 10-98 - �L .ti * aN , END DOCTOR ��7 r'_ _ PMD/ER STAR <.. .: --�--- a, c �i_ —5 ! 'rt7 --_ TIME 10-22 y.. "HOW CHOSEN: TOTAL �' Q STANDBY TIME;: ' ;": •O NEAREST ❑ FAMILY '❑ TRANSFER WAIT TIME ❑ PATIENT ❑ DIRECT ❑ OTHER CALL BACK M: AMBULANCE COMPANY:..,:'�," PT.AMBUTATORY7 PAFIEtJT TAKEN TO AMBULANCE: RESPONSE ZONE f ....t1 • ❑ YES"13NO O WAU:ED ❑ GUERNEY O OTHER '•,PATIENT CONDITION: DRIVERSy 1 /-- f�``I( ' EMT TECH "' <= .a 1 nA ('01,1I• CuIIN 1 Y AMf1UI Alir,l_ / ; t• ''ti • "rlOSPIT•CArlE FORM I UNl7_( AUTHORIZATION M - "{ (-i.��•' 1 Anrnornu tr sricls DATE: ) ' NAME---" 1 t t (` L►.jf u.P _ - - - .cL... ._.. .-- 'IJ M ❑ F COMPANY M 3 Fs RIESSJ ( 11 ' [+ 1 / [_-1 t+ (<< `AGE_ J '•N: �__()STATE ( ZIP ` f2 DOGS - �. O Sn ❑ M ❑ T ❑ W.O Th O ASo "i DRrvER'S LICENSE a PHONE����__-Lail NA7IURE OF DISPATc I -C r _ yI7 PE OF TRANSPORT: AMBULANCE U OTHER U I ` INCIDENT LOCATION: RESPONSE CODE: REQUESTED BY: TIME=(24 HOUR CLOCK) Z; =' i ❑ S O. CALL RECEIVED TO SCENE :.: ) c.0 _ O P.D. TIME 10-8 ,zt PATIENT DESTINATION: FROM SCENE- O FIRE TIME 10-97 'f s _ ❑ pSAP TIME 10-49 e D._-C T 4.'� MILEAGE: 'OTHER/PVT.. TIME 10.7 �� END r; -�.S -- - TIME 10-98 r., ?• - �,•, t� • 'IVOCTOn ..j �( �,ut J .. . .. QAp START. -1 � TIME 1022 ' ' VOW CHOSEN: TOTAL STANDBY TIME'- ,• "p.y ,, r :. q. O NEAREST O FAMILY O l TRANSFE i -.`- WAIT TIME Y O PATIENT ❑ DIRECT ❑ OTHER --�,j? CALL BACK a: AMBULANCE COMPANY::_ t;_{r.. •f PT.AMOULATORV PATIENT TAKEN TO AMBULANCE: RESPONSE ZONE O VES• O NO O WALI<ED';O GUERNEY O OTHER ire I•it,PATIENT CONDITION: DRIVER ' 7+ `Eh4T.-1A • '' };.: '- • TECHNICIAN I PARAMEDIC `^' DISPATCHECEIVED R (THIEF COMPLAINT: �� � � I •. �0, '- tI''`i ITE,I-6AY.RUN: ❑ YES �O NO REASON FOR DRY RUN tt�11 2. AUTHORIZATION FOR DRY RUN(EMS USE MY) 2 O 1:IH2 ` PATIENT REFUSED SERVICES: (SIGNATURE) X E'•� yL 1 i k r. MEDICAL COVERAGE. INDUSTRIAL O YES!" NO NO.OF PATIENTSA µ. . `Lea • ..f'-V 'dr-zt�,._ 1�c, t..�S , L► �� 3 .. , •. .: ..;. ., y:Z PRIVATE IN S.. — BASE RATE: ,S 3S,• I KAISER MULTIPLE PTS. BASE RATE. tF(tUF. C.R(1o9 a TOTAL MILES:-- S� X -X° E.O.B. ATT. ROUND TRIP: ❑ YES O NO '(':` n, F.� L)f�;.j ,'))l.O YES ❑ NO NIGHT: (19:00-07'00) ,,22•CCl/P•PPNP■�._.-. .-. .._-- EMERGENCY RUN: 3 �• 'Y• • £. ;t,M601 CAI. ■ - ---_ CODE 2 r 3 r+:•''ip714cn OXYGEN: (PER TANK) _ tI' P O E $1ICKER O YDS O NO NEONATAL: (INCUBATOR) t d PATES BILLED:—/2/.tJ/sly_!__%�L.S�/� j—�� STANDBY: (OVER 15 MIN.) E K.G.: 'IPER EPISODE) t; + l;,0INfARfST IIELATIVF•IIF-SPONSIRLE PARTY: I.V.: IPER ADA+IN.I .. .,-,--X [X:" -'11^r+ C.'C F (• I% DRUGS: (PEP ADMIN.)__ X . __t. �t•. 'S+• NAXIE 1 ��L i� t.�L`.1 hATIONSH'IP� [� E.O.A.: (IF NOT REPLACED) — - �Z v), a' y�At101IESr, ...._-�- .. ..... ......... ._.-� ORAL AIRWAY: (IF NOT REPLACED) .. CITY _ STATE_—ZIP: C-COLLAR: (IF NOT REPLACED) =,r' W09K PI IONF- _ DRY RUN: (AUTHORIZED) ISS! brOUPATION: OTHER: fY STAT I' S_ E'__--ZIP: r to•' IrN 9 /��1� /i •':0"r ' N' BLUIVED L. : c TOTAL:__-3.#_/S 1 # r • :•u 1 Ar AI+IN1,1 J.:0RATIENT RI CI IVF)) PY- X --.•_ �.TT(.nc� i FIA COSTA COUNTY AMUULANCE �• L, +a 4;.1''1 08P* CARE FORM 1 :,,i UNrT- [W AUTHORIZATION N jon if f�<< {p�0.0010►0)ATESPACEs DATE: S NAME ., ''yLI �) GI/{ .l.l G- IC /4 AJ M Q F COMPANY N a.• 9 j a ))✓ AGE I ( � STATE ��_ up ,`. .:•: F •y } ZIP-�&__ DOB ' O Sn '`O M`:Q T W Q Qr r��g rc1s f� a QRIVER'S LICENSE N PHON J AZURE OF DISPATCH p+, ]YPE OF�RANSPORT. AMBULANCE 0 OTHER LI •' AN I NT OCA�TION. '"`' ' r. `Fr. ) RESPONSE CODE:1ic REQUESTED BY 4TIME.- (24 HOU CLOG )• ►. is-W r:. �p.,. 0 TO SCENE. ci,; S.O. CAi-L RECEIVED" 0 P.D. TIME 10-8 t , ,.PATIENT D TINATIdN: M SCEN - ❑ FIRE ;.TIME 10-97-5 +;' ".4 r ) M ❑ PSAP ,TIME,10-49.g r MIL GE: )(p OTHER/PVT t ' "TIME 1D-7. r _- END 9 ",TIME 10-98�• • .,r'� DOCTOR PMD/ER STAR TIME 10-22 `I •'' x HOW CHOSEN TOTAL ;' ~G V r STANDBY TIME '+ ti 0 NEAREST O FAMILY ,//0Q TRANSFER ; .. ; lfs y . IWAITTIMES� 0 PATIENT 0 DIRECT OTHER ' CALL BACK N. "1 AMBULANCE COMPANY' x�PT.AMULATORYI PATIENT TAKEN TO AMBULANCE: !1 W'i�.y 3 di „� »"r" RESPONSE ZON 0 YES 0 NO Q WAL:•:ED Q GUEhNEY 0 OTHER r' pkPATIENT CONDITION: DRIVER / C.EMT(tA' • Im n/� TECHNICIAN ( • l� PARAMEDICHx. KLUEIV DISPATCHER: LLI f L CHIEJee,COMPLAINT: 1"11- �'=1 DRY RUN: 0 YES 0 NO REASON FOR DRY RUN �' '_ no — AUTHORIZATION FOR DRY RUN(EMS;USE ONLY ' PeRtl I e(` a ARI11 DA' • 'PATIENT REFUSED SERVICES: (SIGNATURE) X 1.;MEDICAL COVERAGE: INDUSTRIAL ON -NO NO,�OF PATIENTS: S.S.# �r PRIVATE INS.CO.: BASE RATE: a f!:KAISER N: �). _ ; MULTIPLE PTS.BASE RATE >�;. . i�t+� =tZ"�t• rf y l: ":x ,' r .BLUE CR9b�S M:' i'✓• TOTAL MILES: X a MEDICA E N:� E�S-80 TT. ROUND TRIP: 0 YES 0 NO §�'• ��� } s� NO NIGHT: (19:00-07;00) 1 � CCHP/PPRP N: EMERGENCY RUN: . o MEDICAL#: CODE 2/3 /2Y ,. � ,,taa'� 's„ OTHER: OXYGEN: (PER TANK) , Y'. �.P.O.E. STICKER 0 YES 0 NO NEONATAL: (INCUBATOR) t r t. ; • DATES BILLED: STANDBY: (OVER 15 MIN) A 1r,�+•,{�r ' ?•rte°i 'i' .. E.K.G.: (PER EPISODE) ���. `b ' "f . '• ..!{..,' Vin..-:.. 't a r:a. . rt ,',,,♦.,,.,parr }I NEAREST RELATIVE/RESPONSIBLE PARTY: I.V.: (PER ADMIN.) X �` t r f�f ( DRUGS: (PER ADMIN.) 1 X r, 5rt NAM RELATIONSHIIY�r t E.O.A.: (IF NOT REPLACED) b ADDRESS: — 7 � ) ORAL AIRWAY: (IF NOT REPLACED) CITY: S STATE ZIP. C-COLLAR: (IF NOT REPLACED) A' I° 7Fyy, PHONE: WORK PHONE: DRY RUN: (AUTHORIZED) EMPLOYER: OCCUPATION' OTHER: '' "!�i�:.!^� � ?` �•%` { k, • ADDRESS: '•' r ,,.:CITY: STATE' ZIP. ° COMMENTS: RECEIVED �,' ---- nllr = '' TOTAL: 7 I. 0S �tlr N V ()I r i w rt,nil Lqr. gMF:11LA 'IFATIENT RECEIVED BY / ' AI(iHA )REI %_.tr94171l4} y NIRA COSTA COUNTY AMBULANCE HOSP AL CARE FORM.1 tWz AUTHORIZATION j f/LL IN APPROPRIATE SPACES DATE «' tSNAME� 7 •�I/�`/�iJ�[- ❑ M F � COMPANYMI ` , a 1 Ar �r DRESS "7C).ti.// �•�;/ �:li)7.'1 i 7flf AGE r,NS'M1SAr Yt='. STATE- L' ZIP DO-8-.—�= •'❑ Sn r0 M)❑ T, W. ❑:Th 9 DRIVER'S LICENSE k PHONE NATURE OF DISPATCH'' ' ' X TYPE OF TRANSPORT: AMBULANCE Q OTHER❑ r`g-~%)a••. •yY i � INCIDENT LOCATION: , it 4.,; RESPONSE CODE•I. REQUESTED BYTIMEi�-x'(24 HOUR CLOCK + r r TO SCENE- , !:�_ � ❑ S.O. CALL RECEIVED " ❑ P.D. t ;TIME-10-8 ' -- ., P E DESTINATION: `I e ( t ,., FROM SCENE 13FIRE `TIME,10 97 ' 7• 1 vA+� f ❑ PSAP i s: )TIME',10-49 x.•.r. ` ��� ;�%%.'"! ///•t e7 . / MILEA '' OTHER/PVT ` �TIME.tQ74. i i.• Y • ;. . . f� '[►T SA ••. END ••. Q�•. r , -.� i'TIME;10-9881:' �. `DOCTOR �Y)T t ! Q 17 PMp[ER_ ,START r tITIME 10.22 'HOW CHOSEN r TOTAL ' -, STANDBY TIME, ❑ NEAREST;. ❑ FAMILY <q TRANSFER I // ,:WAITTIME * PATIENT ❑ DIRECT ❑ OTHER / + ` / CALL BACK k jPt L AMBULANCE COMP Af Y M, f` • r RT.AMBULATORY? PATIENT TAKEN TO AMBULANCE: sw' O,i3O r=> •RESPONSE Z N Y�`❑ YES ❑ NO _ .A.WALKED ❑ GUERNEY ❑ OTHER t , ,rir= . s -a..Y. •;:n� - r, fit .;,. PATIENT CONDITION: ` DRIVER - �' NIT'TA r t TECHNICIAN frAMEDIC Hx: ' r I •�J li- r DISPATCHER: CHIEF COMPLAINT: ��-I F.� DRY RUN: Q YES;(❑ NO REASON FOR DRY-.RUN AUTHORIZATION FOR DRY RUN(EMS USE ONLY) PATIENT REFUSED SERVICES:(SIGNATURE) X 4 MEDICAL COVERAGE:' + '' INDUSTRIAL ❑ YES NO NO;;OF PATIENTS f• ,';, , fly..`y. j• ., , {. '4h .{'� + '.° �'°► .S.S. k '+ ! PRIVATE INS.CO.: 1 BASE RATE. I r ' : �� } r3• ' :,itl. KAISER k: MULTIPLE PTS.BASE RATE ��; `•QY� v BLUE CROSS k: !' TOTAL MILES: �s ^ X4' ti MEDICARE k: O.B.ATT. ROUND TRIP: ❑ YES ❑ NO J�1q 4t' ES `u NO NIGHT:(19:00 07 00) _ r y k. . CCHP/PPRP k: EMERGENCY RUN MEDI-CAL M: CODE 2/3 t ;.[p 'iK OTHER: OXYGEN: (PER TANK) e"., } •�.¢�,�{��+ P.O.E. STICKER ❑ YES ❑ NO / x "•• NEONATAL' (INCUBATOR) p � I.;DATES BILLED: / / •T rr ��f STANDBY: (OVER 15 MIN) ` E.K.G.: (PER EPISODE) _ ;' S� L'•� _�. a T a ''r; ae4 i•, q v �o NEAREST RELATIVE/RESPONSIBLE PARTY I.V.: (PER ADMIN.) ;X• + o0 DRUGS: (PER ADMIN.) X`rl If � t+ NAME: 4 RELATIONSHO -j r E.O.A.: (IF NOT REPLACED) b • ,h h', ADDRESS+`° = ORAL AIRWAY: (IF NOT REPLACED) , ,, ,- ��" CITY: ' /) STATEZIP* C-COLLAR: (IF NOT REPLACED) Y `, PHdNE:r�+ 12 1 CZ iii) WORK PHONE' DRY RUN: (AUTHORIZED) { " I�41 Y 3�tEMPLOYER: OCCUPATION' OTHER: "ADDRESS:- --- i ,..;CITY: STATE' ZIP .,... J ,, I RECEIVED_ COMMENTS; ,.,3 I LIIII, i .c .pr,yljQix•' / TOTAL: .. . T. . ('.ADI= AMRIIIAF PATIENT RECEIVED BY:X ----. _ — - ISIGNATURE) 'i, DBI-TNI) • VCNDon NO I/t DEMAND N0. 204 •s t'-4r)j 16 ,o_JU.,In 13.I U orl file Tren•:nry (it rile Vf)t 1N I N' UI' ('(IN I WA ('l IS I ;� ' Presented By: S1AI1: OFCA1.11'IIRNIA DATE 5-18-82 ; CADILLAC AMBULANCE SERVICE, INC. NAM[ It ASII V10BTI 4601 NEVIN AVENUE IMPORTANT f; Sce Insrruclinns on Reverse Side RICHMOND, CA 94805 CONTRACT p 22-079-8 CITY, STAT[ ZIP COD[ ',j 'r DATE: 7-1-81 to 6-30-82 st ;'•t yl For the sum of ****+**ONE THOUSAND FOUR HUNDRED FIFTY .THREE AND 10/100** ollarr, = 1 -453.10 j As itemized below : PHP MEMBERS DATE DESCRIPTION AMOUNT „ w _. ... rnPWARDED SE CHED '•: - .--. ---'_...__--`-. -- __ a t) 1�1r• :[ PAGES RECEIVED G' MAY20t AMU htlC,li 9�2 ---- --- - — ---- ----- Emergency Medical service RECEIVED r. X C\UIL-L�A1PfBU1�`Ct,� The uudorsigiled umirr th- pt Halt} of pr••rjurL states: That the above Claim and the items as therein set out are true and correct; that no part ihewor has liel:o liewtofore paid. and that file amount therein is justly du � and that the same is presented within one year atter the last item tL•rtent has accrued. signed -,.. .Zf,l •foy' -a`"r�r ---- - -- — vENDen NCI. -� Received, Accepted , and EPpond itur0 Authorized - DEPARTMENT HEAD OR CH1.T T vuv_V6 AG'E?'T1IITi -IT11ltlTflow 7ii11t- 'Actoull �theums"Ailel � N P/C P TM[N AMOUNT � / n/ o / I "-' 1i IL I➢ 1" -1 iY o-191�ri nr PECPLO$ DISCOUNT DUN. ro. urmts OATS 011triPT'IoR Puro 00% AttouRT ENcv■SRANCS SO. P/C ►ATNENT AMOUNT I-- �-- I J A t . TAXA[ NOUN, TAS[ OPTION ACflrnr DISCOUNT , 1 1 iuM ro. INrolE2—Otil "'-"-"-- o[ic•i1:i�oIT ►UNo7wi C. Acr;o`vNi INNCu'M[RANct No ricPATWff% yp IT LTJ_. _s �.- _.l 'TAXABLE AMOUNT IAA. OPTIM ACTIrtTT trlC TLOS I DISCOUNT TT (D15 NP. ;I =" CONTRA COSTA COUNTY AMBULANCE .• , PRE-HOSPITAL CARE FORM I UNIT AUTHORIZATION N -J DATE: f.Nf Lx OA fIU INA IE SPACES y y " PATIENTS NAME 1(' ❑ M O•.F COMPANY Arx --�•---'- 4 ADDRESS — i 1 —_11 :1 / 'l)( ' AGE t T,.,, (' 1 2 .. a .1�t CITY I' STATE ZIP— DOB 1 Y. .11 ❑ Sn ❑ M d ❑T ❑ F i ❑gti { .r DRIVER'S LICENSE N PHONE r:.'_ ._.�'til��i—. NATURE OF DIS �A~` TYPE OF TRANSPORT: AMBULANCE❑ OTHER❑ 1 x' INCIDENT LOCATION:. ) RESPONSE CODE • REOUESTED BY: _ TIME—(24 HOUR CLOCK) 1 / ) , } / ! TO SCENE ❑ S.O. CALL RECEIVED r# .Kxs 'A. ' '� 4'. ! - 1 1 j 1 '•i I. — _ 11P.o. TIME 10-6 '; '.`.r a 3 4+t tasi . PATIENT DESTINATION: FROM SCENE--� ❑ FIRE TIME . ., ( L ❑ PSAP.,• TIME 10-49 i• ? O i 1 IJ MILEAGE: ,.r7 i ❑ OTIIER/PVT TIME 1Q7 y -+-i / — END. —T '•_, '-_ TIME 10 99 .,'.rl oZJ. t S + , DOCTOR_ 4 _. PMD/. 7 _ ► � aID-22_'- Qq START_ ——tL`�1 TIME 10 22 HOW CHOSEN: TOTAL _2_-_l_ >( STANDBY TIME ❑ NEAREST ❑ FAMILY .:❑ TRANSFE{/�' _ _ v WAIT TIME -L ^* ❑ PATIENT 13 DIRECT 11 OTHER !I l'� CALL BACK N: AMBULANCE OMPANY: ►1`.4� {. tea . r; PT.AMBULATORY? PAT IENT TAKEN TO AMBULANCE: ` ,• RESPONSE ZON N r ; . DYES ❑ NO ❑ WALKED ❑ GUERNEV ❑ OTHER I A I T` •1 '� '" 1-' _ - 'f '• 4 PATIENT CONDITION: ? DRIVER- 1_Ctl ••'_I.1 +1"' "'_ ._ —1� as 1. r.•.•u :,` ��� EMT-1A .xJe .•� 1 "''- f - TECHNICIAN ( -APARAMEDIC r e HX* ,•" -_1 '1 ' �r t.•. . :•.r '•L. - DISPATCHER: —1 .__-._..1._.. S si; 1 CHIEF COMPLAINT _L-c- 1?'_,' / . DRY RUN: ❑ YES !y.NO REASON FOR DRY RUN K4 AUTHORIZATION FOR DRY RUN(EMS USE ONLY) ' a ' PATIENT REFUSED SERVICES: (SIGNATURE) X —._ . �. -.MEDICAL COVERAGE: INDUSTRIAL;13YESr&_NO NO.OF PATIENTS: ell. (,rl-{• S.S.N r , ,. •n .I y+ PRIVATE INS.CO.: BASE RATE: KAISER N: MULTIPLE PTS. BASE RATE . :^•x.. BLUE CRO&S.N;—_ TOTAL MILES: X • ..at,�'t2 ,L�`Q ,y, MEDICARE N: _E.O.B.ATT. ROUND TRIP: ❑ YES ❑ NO ---❑ YES ❑ NO NIGHT: (19:00-07:00) CCHP/PPHPN:�—.. -_ ._ —! 1• L� �• EMERGENCY RUN: MEOI-CAL p -- - - .._.— --..._.._.. ---- CODE ?/ i ' OTHER:-----. .:—._-.__ ---_--. OXYGEM (PER TANK) F -r P.O.E STICKER ❑ YES ❑ NO NEONATAL: IwCUBATOR) r� DATES BILLED:__--___ STANDBY IOVER 15 MIN.) b E K.G: (PER EPISODE) `7'r �t 222 NEAREST RELATIVE'RESPONSIBLE PARTY: 1 V: (PER ADMIN) DRUGS: IPEIT A0k8.IN.) . .. —X 5,.•<ff; jpp NAME: ._______ _...___. RELATIONSHIP: _ E.O.A.: (IF NOT REPLACED) ' .j�,`�a•' i ADDRESS: _.....____.___.--____. .._..—_--- ORAL AIRWAY: (IF NOT REPLACED) CITY: ____ -. _.__ STATE _.—_ZIP: C-COLLAR: (1F NOT REPLACED) •"1i-07r'�a 't PHONF: —__.. - _. WORK PHnNE' .—_._ —_ DRY RUN: (AUTHORIZED) •,.,k .) EMPLOYER: OCCUPATION:_.----- OTHER: ADDRESS: CITY: __ --- -- - STATE. ---ZIP:..--- -- --- -._...---- rr C01.4MENTS:_l( r. I 'Prr r)iE t .._. . _..--- I-il.fih TOTAL: _ 1{t (:ACIL.1_A(: rr.�EaJ�n•,I•'; PA TIENT REi.EIVED Rv X _._.—___ _- : { x ... I't. ... ... (SIGNATUREI AMENDED C CLAIM • T . BOARD OF SUPERVI90RS OF CONTRA COSTA 00EPTY. CALIFURNIA BOARD ACTION July 26, 1983 Claim Against the County, ) N(riE TO CLADSW Routing Endorsements, and ) 'lhe copy of this docYWt mailed to you is..your Board Action. (All Section ) notice of the action taken on your claim by the references are to California ) Board of Supervisors (Paragraph III, below) , . Government Code.) ) given pursuant to Goverment Code Sections 913 a 915.4. Please note the *Warning" below. Claimant: State Farm Fire & Casualty Co. (Flores, Robert & Frances Insured) Albany Hill Service Center Attorney: P.O. Box 6265 Albany, CA 94706 Address: - Amount: $902000.00 via County Counsel By delivery to Clerk on July 7, 19831 Date'Reoeived: July 7, 1983 By mail, postmarked on Certified P24 3149073 I. FROM: Clerk of the Board of Supervisors TO: County Counsel AMENDED Attached is a copy of the above-noted Claim. DATED: 7/7/83 J.R. OISSON, Clerk, By , Deputy Reeni malijao II. FROM: County Counsel TO: Clerk of the Board of Supervisors (Check one Orly) �ieaJff (x) Thi�Claim oomplies substantially with Sections 910 and 910.2. ( ) This Claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8) . ( ) Claim is not timely filed. Board should reject claim on ground that it was filed late. (§911.2) DATED: -4- (J S JOHN Be CGAiJSIIJ. County Counsel r BY Deputy III. BOARD OR ER By unanimous vote of Supervvxjfff i rs present ( X) MUrslclaim is rejected in full. ( ) This claim is rejected in full because it was not presented within the time allowed by law. I certify that this is a true and correctof the Board's Order entered in its minutes for this date. DATED: JUL 2 6 1983 J.R. CaSSON, Clerk, by - _ . Deputy SING (Gov't. C. 5913) Subject to certain exceptions, you have only six (6) months from the date this notice was persopally delivered or deposited in the mail to file's court action on this claim. See Government Code Section 945.6. You may seek the advice of any attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. IV. FROM: Clerk of the Bomd T0: County Counsel, 2 County strator Attached are copies of the above Claim. We notified the claimant of the Board's action on this Claim by mailing a copy of this doewent, and a nam thereof has been filed and endorsed on the Board's copy of this Claim in accordance with Section 29703. DATED:. J. R. &SSON, Clerk, by Deputy - 181 STAT[ lAPM INSU0.ANCE State Farm Fire and Casualty Company Albany Hill Service Center June 22 , 1983 Post Of icerce Boxtreet 6265 Albany,California 94706 Phone: (415) 527-6273 Board of Supervisors Contra Costa County 651 Pine Street , 1st Floor Martinez , CA 94553 CERTIFIED MAIL RE : Claim Number : 470 024 Date of Loss : 03 31 83 Location : 4622 Driftwood Court , E1 Sobrante , CA Insured : Flores , Robert & Frances Gentlemen : Our investigation of this loss has revealed that you are respon- sible for the property damage to our insured ' s property. Due to your failure to abate the dangerous condition , our insured has suffered a severe loss to his property. This letter will serve as notification of our subrogation interest in the amount of $90,000. 00. A follow-up letter in detail with related reports , theory of liability , and cost will follow. Should you have any questions regarding this loss , please feel free to contact my office by phone or mail. Very truly yours , ) /� L IE NOLAND RECEIVED Sr. Field Claims Representative LN : as JUI4 24 I ` J. R. OLSSON 0 D OF SUPERVISORS CO. Deputy �. 71,77o 7o 182 HOME OFFICE: BLOOMINGTON, ILLINOIS 6 1 70 1 ` AMENDED ` CLAIM BOARD OF SUPERVISORS OF CO6TRA COSTA COUNTY, CAIITaOIA BOARD ACTION ' Claim Against the County, ) NOTE TO CLA214 July 26, 19$3 ibuting Endorsements,, and ) The copy of this document mailed to you is your Board Action. (All Section ) notice of the action taken on your claim by the references are to California ) Board of Supervisors (Paragraph III, below) , Government Code.) ) given pursuant to Government Code Sections 913 & 915.4. Please note the "Warning" below. Claimant: State Farm Fire & Casulaty Co. (Bricker, Harold R. Insured) Albany Hill Service Center. Attorney: P.O. Box 6265 ' Address: Albany, CA 94706 _ _ - Amount: $509000.00 via County Counsel By delivery to Clerk on July 7, 1983 Date'Received: By mail, postmarked on Certified P24 1149042 I. FROM: Clerk of the Board of Supervisors TO: County Counsel AMENDED Attached is a copy of the above-noted DATED: 77'7/83 J.R. OLSSON, Clerk, By. Deputy Reeni Malfatto II. FROM: County Counsel TO: Clerk of the 13oard of Supervisors (Check one gnly) fint,nded (X ) This4Claim complies substantially with Sections 910 and 910.2. ( ) This Claim FAILS to ooply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (section 910.8) . ( ) Claim is not timely filed. Board should reject claim on ground that it was filedC late. (§911.2) DATED: C 3 JOHN B. a AUSEN, County Counsel, By . Deputy III. BOARD ORDER By unanimous vote of sors pre t (� T.hisclain is rejected in full. ( ) This claim is rejected in full because it was not presented within the time allowed by law. I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. DAM: JUL 2 6 1983 J.R. mssm, Clerk, by � .�,z( Deputy iARM;G (Gov't. C. $913) Subject to certain exceptions, you have only six (6) months from the date this notice was persopally delivered or deposited in the mail to file's court action on this claim. See Government Code Section 945.6. You may seek the Advioe of any attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. IV. FROM: k of the Board TO: 1 County Counsel, 2 County strator Attached are copies of the above Claim. We notified the claimant of the Board's action on this Claim by mailing a copy of this document, and a man thereof has been filed and endorsed on the Board's copy of this Claim in accordance with Section 29703. DAM: J. R. OLSSON, Clerk, by . Deputy 183 c- STATE FARM � 7 INSURANCE State Farm Fire and Casualty Company • Albany Hill Service Center 3254-B Pierce Street July 5 . 1983 Post Office Box 6265 Albany,California 94706 Phone: (415) 527-6273 Mr. John B. Clausen CERTIFIED MAIL County Counsel P. O. Box 69 Martinez , CA 94553-0116 RE : Claim Number : 470 024 Date of Loss : 03 31 83 Our Insured : Flores , Robert & Frances Location : 4622 Driftwood Ct . , El Sobrante , CA 94803 Dear Mr. Clausen : We have received your notice of insufficiency and/or non- acceptance of claim. This letter is to advise you that we desire that you present all notices to P. O. Box 6265 , Albany , California, 94706 (3254-B Pierce Street , Richmond, CA 94804) . Our information is that as early as 1978 , the County placed Dennis and Becky Woodrift on notice to cease and quit illegal dumping. This illegal dumping blocked the culvert , and in M4rch 1983, this blocked culvert caused a ponding effect behind the slide which allows water to percolate under the hill and is a direct cause of the landslide problem experienced by our insured. The County of Contra Costa is negligent in the handling of this matter. This illegal dumping and blocked culvert has never been remedied. And the nuisance continued to exist and to cause problems to the lateral support . This letter is notice of our subrogation interest in this matter . Ver/ truly yours , �� 6 ,W�— XW Couaty Counsel LILLIE NOLAND Sr. Field Claims Representative JUL U 6 1983 LN :as Mkare;nez, CA 94553 HOME OFFICE: BLOOMINGTON. ILLINOIS 6 1 70 1 r 1 •�r .r • • Si�iE r�pM IN SUp�NCE State Farm Fire and Casualty Company Albany Hill Service Center 3254-B Pierce Street June 22 , 1983 Post Office Box 6265 Albany,California 94706 Phone: (415) 527-6273 Board of Supervisors Contra Costa County 651 Pine Street , 1st Floor Martinez , CA 94553 CERTIFIED MAIL RE : Claim Number : 470 066 Date of Loss : 03 31 83 Location : 4642 Driftwood Court , E1 Sobrante , CA 94803 Insured : Bricker , Harold Raymond Gentlemen : Our investigation of this loss has revealed that you are respon- sible for the property damage to our Insured' s property. Due to your failure to abate the dangerous condition , our insured has suffered a severe loss to his property. This letter will serve as notification of our subrogation interest in the amount of $50 ,000. 00. A follow-up letter in detail with related reports , theory of liability, and cost will follow. Should you have any questions regarding this loss , please feel free to contact my office by phone or mail. Very truly yours , L LLIE NOLAND Sr. Field Claims Represenative LN : as RECEIVED JUN 24 iia; J. R. OLSSON CLE OARD OF SUPERVISOR$ 185 HOME OFFICE: BLOOMINGTON, ILLINOIS 61701 ORDINANCE NO. 83-29 Re-Zoning Land in the Oakley Area) The Contra Costa County Board of Supervisors ordains as follows: SECTION I. Page H-25 of the County's 1978 Zoning Map (Ord. No. 78- 93) is amended by re-zoning the land in the above area- shown shaded on the map(s) attached hereto and incorporated herein (see also County Planning Department File No. 2552-RZ ) A-2 General Agriculture FROM: Land Use District R-7p ( Single Eami_ly Residential ) TO: Land Use DistrictP-1 ( Planned Unit Development ) and the Planning .Director shall change the Zoning Map accordingly, pursuant to Ordinance Code Sec. 84-2.003. RIO e.. v A-2 g !� QV ' o � •:ti•: t:(:'r: X11 r ! i -- _ FR-2 ------------------- A2_ -------------- --I. I I I . l SECTION II. EFFECTIVE DATE. This ordinance becomes effective 30 days after passage, and within 15 days of.passage shall be published once with the names of supervisors voting for and against it in the BRENTWOOD NEWS a newspaper published in this County. PASSED on July 26, 1983 by the following vote: Supervisor Aye No Absent Abstain 1. T. M. Powers ( ) ( ) ( X) ( ) 2. N. C. Fanden ( X) ( ) ( ) ( ) 3. R. I. Schroder ( X) ( ) ( ) ( ) 4. S. W. McPeak ( X) ) ( ) 5. T. Torlakson ( X) ) ATTEST: J. R. Olsson, County Clerk and ex officio Clerk of the Board Chairman of the Board Dep. (SEAL) Diana M 4erman ORDINANCE NO. 83-29 18 2552-RZ CONTRA COSTA COUNTY �.. APPROPRIATION ADJUSTMENT T/C 27 '= ft ACCOUNT CODING I. DEPARTMENT OR ORGANIZATION UNIT: L E� TI e/V� , ORGANIZATION SUB-OBJECT 2. FIXED ASSET / SE OBJECT OF EXPENSE OR FIXED ASSET ITEM NO. QUANTITY `ECREAS> I,NC,AEASE 0043 1011 Permanent Salaries 8 , 000 1013 Temporary Salaries 34";000 1014 Permanent Overtime 11000 1042 F. I .C.A. 4 , 000 " 1044 Retirement Expense 3, 500 2100 Office Expense 20 , 00.0 2110 Communicati9_rls-- 61000 2111 Telephone Exchange Service 10 , 700 " 2150 Food 350 " 2190 Publication Legal Notices 2 , 800 " 2276 Maintenance Radio-Electronic Equip 3, 500 " 2301 Auto Mileage Employees 900 " 2310 Professiona/Specialized 1 , 000 2315 Data Processing Services 71300 2316 Data Processing Supplies 1 , 000 " 2250 Rents & Leases - Equipment 31 ,580 2260 Rents & Leases - Property 140 " 2261 Occupancy Costs Rental Building 22 , 500 " 2270 Maintenance - Equipment 11 , 190 2303 Other Travel Employees 580 " 2465 Elections Offices 5 , 540 2473 Specialized Printing 53 , 000 " 2479 Other Specialized Departmental Exp. 6 , 000 2490 Miscellaneous Services & Supplies 910 " 5022 Cost Appld - Services & Supplies 14, 360 13/, 44-0 Ill'. N o 0990 6301 Reserve for Contingency 13 , 030 0990 6301 Appropriable New Revenue 96 ,-910 - APPROVED 3. EXPLANATION OF REQUEST AUDITOR-CO TROLLER JUL 1410 o Reconcile Accounts By: Dote COUNTY ADMINISTRATOR By: k1l AN Dote BOARD OF SUPERVISORS pcev�re Fallen, YES: /fS.ra&r,WPeak,TurlAum NO: G �olcu�a On jUk 2/6 19 33 J.R. OLS N, CLERK 4. 71134 81 E TOIL E - DATE By APPROPRIATION A POO . y ADJ. JOURNAL NO. (M 129 Rev. 7/77) SEE INSTRUCTIONS ON REVERSE SIDE 187 CONTRA COSTA `COUNTY ! APPROPRIATION ADJUSTMENT T/C 2 7 1 I. DEPARTMENT OR ORGANIZATION UNIT: ACCOUNT CODING N)i ORGANIZATION SUB-OBJECT 2. FIXED ASSET /DECREAS> INCREASE OBJECT OF EXPENSE OR FIXED ASSET ITEM NO. OUANTITT 0990 : ' /oo.oa 0211 1011 PERMANENT SALARIES 52,000.0( 0211 2100 OFFICE EXPENSE 15,000•pq 1 0211 2111 TELEPHONE EXCHANGE 3,000.x4 0211 2250 RENTS & LEASES EQUIPMENT 5 ,000. 0( 0211 2261 OCCUPANCY COSTS RENTED BUILDING 1,000•,D 0211 2262 OCCUPANCY COST 12,500.0( 0211 2270 MAINTENANCE EQUIPMENT 3,500-,,e 0211 2284 REQUESTED MAINTENANCE 6 ,000-n 0211 2301 AUTO MILEAGE 11,800.0( 0211 2310 PROFESSIONALJEPECIAL SERVICES 26 ,000.0( 0211 2316 DATA PROCESSING SERVICES 13)5001-" 0211 2316 DATA PROCESSING SUPPLIES 5,000 -m 0211 2303 OTHER TRAVEL EMPLOYEES 310100.0( 0211 2351 JURY FEES & EXPENSES 20,000.,, 0211 2477 EDUCATION SUPPLIES & COURSES 500 .,e 0211 71 7f) HOTMEROT-T) VyPvwqv 80o gj APPROVED 3. EXPLANATION OF REQUEST AUDITO CON TIROLLE FJ Reallocating Internal Surplus Fun& in certain B Date ////8 accounts to cover projected/estimated shortages COUNTY AD INISTRATOR for 19.82/83 budget. By: Date There may still be an overall shortage of BOARD OF SUPERVISORS approximately ,42,100.00, which we seek the Supomiwn 4lomerFandm. YES: Schn>,1er,A1cPoak,Tudakhill Board of Supervisors to approve an adjustment. N0: ilo� o„JU� 419 3 J.R..0 S,S<tjm If SIGNATURE TITLE DATE By: APPROPRIATION A P00 ,&_39D ADJ. JOURNAL NO. (M 129 Rev. 7/77) SEE INSTRUCTIONS ON REVERSE SIDE 18H lCONTRA COSTA COUNTY APPROPRIATION ADJUSTMENT L J T/C 2 7 ACCOUNT CODING I. DEPARTMENT OR ORGANIZATION UNIT: PUBLIC WORKS (ROADS) FY 82-83 ORGANIZATION SUB-OBJECT 2. FIXED ASSET OBJECT OF EXPENSE OR FIXED ASSET ITEM NO. QUANTITY DECREAS, INCREASE 0661 2310 PROFESSIONAL SERVICES 3,000.00 0360 2310 PROFESSIONAL SERVICES 3,000.00 APPROVED 3. EXPLANATION OF REQUEST AUDITOR-CONTROLLER / / TRANSFER FUNDS FROM CROSSING GUARDS TO COVER By: Date COSTS INCURRED IN RELOCATION OF SCHOOL FLASHERS AND ADDITIONAL MODIFICATIONS AT PACHEOD BLVD/LAS COUNT ADMINISTRATOR JUNTAS SCHOOL IN MARTINEZ. (WO 6179) By: 41 CP AA Dote /7V BOARD OF SUPERVISORS $un•n'iwrs.���,Fuh.lrrt, YES: S.tuuirr,Mal'r:ik,1'u1:'ks«n. NO: /` \ 1 o 1 , 2 619 3 ; — __t ; J.R. OLSSO CLE K UBLIC WORKS DIRECTOR 7 / 19/ 83 IA� E TITLE p�f DATE By: APPROPRIATION A POO 6/ 7 ADJ. JOURNAL NO. (M 129 Rev. 7/77) SEE INSTRUCTIONS ON REVERSE SIDE 189 TO: BOARD OF SUPERVISORS FROM: M. G. Wingett, County Administrator ,,ntra C ,la / DATE: July 18, 1983 SUBJECT: Legislation--Assembly Bill 307 (Allen) ZPECIFIC REOUESTISI CR RECCI•NEFDATION(S ) d 8ACKCJ1tCAJN0 AfD JUSTIFICATION RECOMMENDATION: Adopt a position in favor of AB 307. 's BACKGROUND/JUSTIFICATION: Under present law, the Director of Food and Agriculture may annually allocate to each county up to one-third of the amount expended by the county for the local administration and enforcement of weights and measures programs, and up to one-third of the amount expended by the county for certain programs that are jointly administered by the director and county agricultural commissioners. The allocations are required to be made from funds appropriated to the director for the purposes of these programs. This bill would instead require the director to make those allocations in an amount which is not less than one-third of those county expenditures. This bill would increase revenue to the County by approximately $100,000 per year. The Agricultural Commissioner-Director of Weights and Measures recommends that your Board support AB 307. LATIN O N AT N V SIGNATUAC• ' :O U C O T•C I Y+C T; � yes "CC O"m l:fJO.11014 Or COLO"TV AD"IN SYR A TOIL IICCO""r NOATION Or 110A110 Cr MITI1.1: X •r•1•I.OV[ ._.. OTNCR. Iou 0. nn.l.n o.1 July-26-.. 3.1_.---. ..... •1•1•urlV rrl A5 nr r.ouur.r.n rn (1114tH I IE:TIC LIV CCITT try TIUI 11415 1 ': A 11luC 111+AfJlI.I C.}15 (AnfiC/+T �..- AIIIJ CORnCCT CCPV Or All ACTICVJ TAKC/J AVC'i KlC5•• AI111 r,lTGnrO CVJ TTI: ,.,IIIITI:5 of 1111: IV7Arin A USC NT AU:iTAIN:--_----_..- Or ;'AJI•CIIV 15XJ15 OIJ TAR-' DAIC 51IJwlJ, CC County Administrator Ar1C5iTC11 __..._ C� H Agricultural Commissioner J 'n oLa- COI.IIJT•V CLCIM Assemblywoman Doris Allen A?In 'r} Orl' IC 10 CL EO'" rl1" TIIC 00AnD Assemblyman Norm Waters, Chairman Agriculture Committee fly _ UC r.UTV Larry Naake, CSAC Director - 190 TO: BOARD OF SUPERVISORS Contra FROM: M. G. Wingett, County Administrator �,� /CW la } 6KTE: July 18, 1983 C SUBJECT: Legislation--Assembly Bill 1312 (Connelly) -ECIFIC REG(JEST( S ( OR RECO•44ENDATION(S) 6 6ACKC.ROUN1) AJa JUSTIFICATION r RECOMMENDATION: Adopt a position of support for AB 1312. BACKGROUND/JUSTIFICATION: Current law requires a fee of $200 for filing a notice of appeal in a Civil case to a court of appeal . AB 1312 would, in addition, require a deposit of $50 with the originating court. The deposit would be credited against the amount charged for preparation of the Clerk' s transcript, or for indexing in lieu of preparation of the Clerk's transcript, but would be forfeited in the event the appeal is abandoned or dismissed prior to filing of the record in the Court of Appeals. The deposit would be refunded upon a showing that the record on appeal was perfected without a Clerk's transcript or indexing. AB 1312 would tend to discourage frivolous appeals and would provide some additional revenue to the courts in those cases as well as providing some revenue "up front" prior to the actual preparation of the transcript. The Clerk-Administrator of the Walnut Creek-Danville Municipal Court recommends that your Board support AB 1312. -ONTINVCO ON ATT.C,NCNT; TCS 31GNATVf.C: [/L,^I%�^C!A •� _�- • l • `l!1!/✓V L' Jlf;" `W v•� �_ _ ..1:1.0.7101. Or COUNTY ADMINISTRATON IICCO..N(NO.///Tiol, OC 910.I10 X- u•rr.OVC _._-. OTO CN 91rNA TIJIiC ( i 1. G t .C. I .U., 0. nn..•i. 0.1 ' Ju y26. 8a__:_._._ 1111. .. •••....nvrn .s ur:c n..N r_r.n cr. n7.n'u Vl. TC Of 1 In:IICIIT CCITTIf V TINT 11115 1 :: A TIiUC IIN All Ir.1(,11i IAnsC17T 1/ Af UJ CORRCCT COY Or AH ACT ICM TAKCI! ATC;: _ Nor S ^rir, C/Rcn F-D C'H4 TI/: Ia1IO1T1:S Of Till: Ih Afln A(lSCrlT Af1STA1N:•-_---y--~— Of ,'AJI•CNV1;lJ1,1' g . _._ -_ a OfJ Tin: nATC IO�WIl. ('C County Administrator A'VIC.xTl: ) Assemblyman Lloyd Connelly � J. C(DiVITY CLE1414 Senator Barry Keene, Chairman Affl rk txr lc In C1.1:i1I( rir TIJr (rjAnn Judiciary Committee Senator Daniel E. Boatwright Senator Nicholas Petris "`I�'Tv 191 Of Y ' • - BOARD OF SUPERVISORS ID"+: COUNTY ADMINISTRATOR Contra Costa `TE : July 21>, 1983 Cointy ,EJECT: Oppose Assembly Bill 46 (Floyd) -ECIFIC REQUEST S ( OR RECOMMENDATIONS) & BACKGROUND AND JUSTIFICATION Recommendation: Oppose AB 46 (Floyd) which would increase allowable truck weights and ignore the potentially disastrous damage to local roads. Background/Justification: The effect of AB 46 is to allow refuse collection trucks to carry a weight of up to 48,000 pounds on a tandem axle. Such weights are illegal on the federal Interstate System (amended out of the bill ) , but even with such an exclusion, reports the Federal Highway Administration, " The weights which would be authorized by AB 46 are so excessive that potential violations of other sections relating to standards and maintenance could be violated. . . . More importantly, California highway pavement and bridges would be affected in some instances, critically." This is a clear indictment of the bill and demonstrates the devastating impact this measure will have on local streets and roads at a time when counties and cities are barely able to protect their transportation investment with greatly reduced revenues. The Public Works Director and the County Administrator recommend the Board OPPOSE AB 46. 1 J Michae ford JNTINUED ON ATTACH ENT: YES SIGNATURE: Public Works Director RECOMMENDATION OF COUNTV ADMINISTRATOR RECOMMENDATION OF BOARD COMMITTEE APPROVE TNER IGNATURE S / k :TION OF DOARO ON ti- APPROVED AS RECOMMENDED OTMCR ATE OF SUPEFIV I S i5 1 HEREBY CERTIFY THAT THIS IS A TRUE _ UNANIMOUS IADGENT �/ AND CORRECT COPY OF AN ACTION TAKEN AYES: _. -.-..--. NOES. AND ENTERED ON THE M I FiJTES OF THE BOARD ABSENT: ABSTAIN: _ OF SUPERVISORS CMJ THE DATE SHOWN. : CC: County Administrator ATTESTED County Legislative Delegation J.R. LSSO couNTY CLERK Public Works Director Aro Ex OFFICIO CLERK Or THE BOARD Director of Planning County SupTransportation Co Calif. �� p//h DEPUTY Senate Transportation Committee BY , 192 THE BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Adopted this Order on July 26, 1983 by the following vote: AYES: Supervisors Fanden, McPeak, Torlakson, Schroder NOES: None ABSENT: Supervisor Powers ABSTAIN: None SUBJECT: Authorizing Appointment of Eileen Phillips, Account Clerk III As requested by the Probation Department and recommended by the Director of Personnel, IT IS BY THE BOARD ORDERED that reemployment of Eileen Phillips in the class of Account Clerk III at the third step ($1502) of Salary Range H2-100 ($1362-1656), effective August 1, 1983 is APPROVED. I hereby certify that this is a true and correct copy of an action taken snd entered on the minuies of the Board of Supervisors on the date shown. ATTESTED: JUL 2 6 WAW J.R. OLS SON, COUNTY CLERK .end ex o fico Clerk of the Board By , Deputy Orig. Dept.: personnel Cc: County Administrator Auditor-Controller Probation 193 POSITION ADJUSTMENT REQUEST No. Date: 7/5/83 Dept. No./ :.,� ='•� ..•! +L' �.4 Copers Department Health services/Public Budget Unit No. 0450 r No. 5802 Agency No. 54 ea t 411 r 1I 216 ,Action Requested: NON-ROUTINE: Transition perso (s ndra eow and position of Public Health Dental Hygienist - roject, b4-2213, to c x section 1603 of the Fersonnei Managementegu a ions Proposed Effective Date: .7/27/83 Explain wh� adjustment is needed: Funding for the Dental Disease Prevention program is expected o continue for the foregeeaj5le future Classification Questionnaire attached: Yes Q No I Estimated cost of adjustment: $ p Cost is within department's budget: Yes 0 No If not within budget, use reverse side to explain how costs are to be funded. Department must initiate necessary appropriation adjustment. Ray Philbi Use additional sheets for further explanations or comments. Personnel ices Assistant for Depart ent Head Personnel Department Recommendation Date: -7—/9 -23 Transition person (Sandra Leow) and position of Public Health Dental Hygienist - 28/40 Project, #54-2213, Salary Level H2 372 (1788-2173) to classified status per Section 1603 of the Personnel Management Regulations. Amend Resolution 71/17 establishing positions and resolutions allocating classes to the Basic/Exempt Salary Schedule, as described above. �/� Effective: pq day following Board action. 1L1 Ll C Date fo Director of P sonnel County Administrator Recommendation 7p?Q (,3 Date: Approve Recommendation of Director of Personnel O Disapprove Recommendation of Director of Personnel 0 Other: f � for County Administrator Board of Supervisors Action Adjustment APPROVED/ 49APPRBYEon JUL 2 6 1983 J.R. Olsson, County Clerk Date: -- JUL 2 61983 By: APPROVAL OF THIS ADJUSTMENT CONSTITUTES A PERSONNEL/SALARY RESOLUTION AMENDMENT. M347 6/82 194 CONTRA COSTA COUNTY HEALTH SERVICES DEPARTMENT j PUBLIC HEALTH DIVISION To: Ray Philbin Date: June 22 , 1983 From: lenn L. Wh' te Subject : PROJECT POSITIONS 54-1838 $ 54-2213 Following receipt of your memorandum on June 1 , we have thoroughly assessed the situation regarding the two subject positions . In so doing , we have ascertained that funding for the twoZr��rams is f_ir�f_o��'��� i year ani ere is every indicatio�trat this situation will continue urin t e oreseea e tuture . Tris being -the case, it is our request that each ot these pose ions be transitioned from their current project status to the status of full-time, classified positions . The Public Health Nutritionist-Project position, (position #54- 1838) now held by Audrey Dean, is currently a PI position being worked about 28 hours per week in the WIC Program and some addi- 1,� tional hours in the teen programs . Due to the loss of our Chief Nutritionist, we have determined that it will be in the best interests of the Public Health service to permanently increase V� the hours of that position to full-time. Funds are available in the fiscal year 1983-84 budget to underwrite the limited addi- tional expense. Since we have so many requests for nutrition consultation from among the many Public Health projects and/or Public Health activities , it is vital that we have the addition- al hours of consultation time . Whenever possible , the consul - tation time will be charged to appropriate projects . Since we have no appropriate "tradeoff" hours , please utilize the personnel pool as necessary. The necessary documentation to accomplish the above is enclosed. Please make the above requested personnel actions effective on July 1 , or as soon thereafter as feasible . Please advise. Thank YOU for your prompt attention to these matters . GLW: lh Enc . cc : Linda Lilly Peggy Tolley Helen Nielsen GA-9 8/81 SM 195 POSITION ADJUSTMENT REQUEST No. /3 63 �2— Date: 7/5/83 Dept. No./ F (JC, a Copers Department Health Services/Public Budget Unit No. 04 o Org. No. 5828 Agency No. r,4 _ Health Xb It Action Requested: -R Transition person (Audre Dean) and Posi ion of Public Health Nutritionist-P.I. Project, 54-1838, to classified statdVj4e taE!rr)k6@� of the Personnel Management Regulations. Proposed Effective Date: 7/27/83 Explain why adjustment is needed: Funding for the Women;: Infants, and Childrens (WIC) program is expected to continue for the foreseeable future. 764M44"tWi%€w attached: Yes Q No Position description Estimated cost of adjustment: $ 0 Cost is within department's budget: Yes 0 No [] i If not within budget, use reverse side to explain how costs are to be funded Department must initiate necessary appropriation adjustment. Ray Philbin Use additional sheets for further explanations or comments. Personnel S ices As i t! for Department Head Personnel Department Recommendation Date: 7—/9 -83 Transition person (Audrey Dean) and position of Public Health Nutritionist P. I. Project, #54-1838, Salary Level H2 350 (1749-2126) to classified status per Section 1603 of the Personnel Management Regulations. Amend Resolution 71/17 establishing positions and resolutions allocating classes to the Basic/Exempt Salary Schedule, as described above. Effective: day following Board action. D Date forDire r o Personnel County Administrator Recommendation 7 a0 Date: Approve Recommendation of Director of Personnel O Disapprove Recommendation of Director of Personnel O Other: 11 for County Administrator Board of Supervisors Action JUL 2 61983 Adjustment APPROVED/ft5WR9'M on J.R. Olsson, County Clerk Date: JUL 2 61983 PROVAL OF THIS ADJUSTMENT CONSTITUTES A PERSONNEL/SALARY RESOLUTION AMENDMENT. M347 6/82 196 CONTRA COSTA COUNTY HEALTH SERVICES DEPARTMENT PUBLIC HEALTH DIVISION To: Ray Philbin Date: June 22 , 1983 57 From: Tenn L. White Subject : PROJECT POSITIONS A� 54-1838 & 54-2213 Following receipt of your memorandum on June 1 , we have thoroughly assessed the situation regarding the two subject positions . In so doing , we have ascertained that fundingfor the two ro rams is firm for e nexti ear n ere is ever indication t at this situation wilkcontinue during the toreseeable to urs . Tris eing a case, it is our request that each ot these positions be transitioned from their current project status to the status of full-time, classified positions . The Public Health Nutritionist-Project position, (position #54- 1838) now held by Audrey Dean , is currently a PI position being 1r worked about 28 hours per week in the WIC Program and some addi- �j ia�( tional hours in the teen programs . Due to the loss of our Chief Nutritionist, we have determined that it will be in the best interests of the Public Health service to permanently increase the hours of that position to full-time . Funds are available in the fiscal year 1983-84 budget to underwrite the limited addi- tional expense. Since we have so many requests for nutrition consultation from among the many Public Health projects and/or Public Health activities , it is vital that we have the addition- al hours of consultation time. Whenever possible, the consul- tation time will be charged to appropriate projects . Since we have no appropriate "tradeoff" hours , please utilize the personnel pool as necessary. The necessary documentation to accomplish the above is enclosed. Please make the above requested personnel actions effective on July 1 , or as soon thereafter as feasible . Please advise . Thank you for your prompt attention to these matters . GLW: lh Enc . cc : Linda Lilly Peggy Tolley Helen Nielsen GA-9 8/81 5M 197 POSITION ADJUSTMENT REQUEST Date: June 16, 198 Dept. Iao F ! F U Copers Department Auditor-Controller Budget Unit No. OlD Org. No., 1015 Agency No. Action Requested: Reclassify Clerk-Senior fevi , P sli on t-50, and incumbent to ccount clerk C!ViL 5ERVICE DEPT, Proposed Effective Date: ASAP Explain why adjustment is needed: To align classification with duties being performed. Classification Questionnaire attached: Yes No Estimated cost of adjustment: $ -0- Cost is within department's budget: YesFA] No If not within budget, use reverse side to explain how costs are tobe d. Department must initiate necessary appropriation adjustment. Use additional sheets for further explanations or comments. epar t Head Personnel Department Recommendation Date: July 19, 1983 Reclassify person and position of Clerk-Senior Level , position 10-050, salary level H2 012 (1247-1516) to Account Clerk III, salary level H2 100 (1362-1656) . Amend Resolution 71/17 establishing positions and resolutions allocating .classes to the Basic/Exempt Salary Schedule, as described above. Effective: p day following Board action. D Date qforDirec );ejorlsonneI County Administrator Recommendation Date: q—;Z �B3 VtApprove Recommendation of Director of Personnel O Disapprove Recommendation of Director of Personnel C3 Other: f rCounty Admin 3 rator Board of Supervisors Action Adjustment APPROVED/49_%APPRW�EB on J U L 2 6 1983 J.R. Olss Count Clerk Date: JUL 2 61983 By: APPROVAL OF THIS ADJUSTMENT CONSTITUTES A PERSONNEL/SALARY RESOLUTION AMENDMENT. M347 6/82 198 :Y / 30 / q , . POSITION ADJUSTMENT REQUEST No. l 36 4 !f Date: 7/13/83 Dept. N9• - k;4-tAo - 1-.t Copers Department Health Services/MC Budget UA--���LLo. �p g. No.6598 Agency No. 54 Action Requested: Add one (1) P. I. Security, at'tY po�'s t oon in cost center 6598• cancel Institutional Services Aide P. I. 49gtJ91a ROUTINE Proposed Effective Date: 7/ 7183 Explain why adjustment is needed: Classification Questionnaire attached: Yes No ® - Memo attached Estimated cost of adjustment: $ Cost is within department's budget: Yesx0 No If not within budget, use reverse side to explain how costs are to be funded. Department must initiate necessary appropriation adjustment. Andrea Jackson Use additional sheets for further explanations or comments. Personnel Service ssistant for Department Head Personnel Department Recommendation Date: 7—/ 5 —g-3 Add one P. I. Security Guard position ; cancel Institutional Services Aide P. I. position #54-1678. Security Guard Salary Level H5 140 51563-1/23) ; Institutional Services Aide Salary Level H1 817 (1029-1250). Amend Resolution 71/17 establishing positions and resolutions allocating classes to the Basic/Exempt Salary Schedule, as described above. Effective: [g) day following Board action. Cl Date for Directo of ersonnel County Administrator Recommendation Z�E3 Date: Approve Recommendation of Director of Personnel [] Disapprove Recommendation of Director of Personnel 0 Other: for County Administrator Board of Supervisors Action Adjustment APPROVEDt5*SAPf @VE+ on JUL 2 61983 J.R. Olss County Clerk Date: JUL 2 61583 B . APPROVAL OF THIS ADJUSTMENT CONSTITUTES A PERSONNEL/SALARY RESOLUTION AMENDMENT. M347 6/82 199 t' 1 -� CONTRA COSTA COUNTY HEALTH SERVICES DEPARTMEWE: ` � �_- ' ' E. ,.►u�_ 1� �� s4 AM ��3 C!VIL SEF;`110E t�EoT. To: William Ray pate: July 13, 1983 Supervising Personnel Analyst From: Andrea Jackson` Subject: P-300's - ESTABLISHMENT OF CLERK Personnel Services Assistant AND SECURITY GUARD POSITIONS Attached are two (2) P-300's to establish one (1) P.I. Clerk-A (Typing Required) position and one (1) P.I. Security Guard position for the Medical Care Division. The P.I. clerical position is needed to provide coverage in various sections (e.g. radiology, dental, business office, financial clearance, appointment desk, medical records) of the Pittsburg and Brentwood Health Centers and the Pittsburg and Antioch Mental Health Clinics. With the clerical cutbacks that have accrued during the last few years in East County and the resulting low ratio of personnel, it has become impossible to accomplish all clerical duties when clerks are sick, on vacation, or emergency leave, on leave of absence, or a position is vacated. Currently many of these areas are left uncovered due to lack of coverage, and patient care suffers. Attached is a class questionnaire depicting the duties of the position. Please be advised that we may be requesting three (3) additional P.I. clerical positions in the near future. The P. I. Security Guard position is needed to provide added security to the Pittsburg facilities. As the attached memo from Ms. Judi Sizemore indicates, the lack of security coverage is interfering with patient care. This position will enable us to cut back on the Security Guard overtime, allow us to admit patients after 4:30 p.m. and increase employee safety and morale. Please agenda these P-300's for the 7/26/83 Board of Supervisors meeting. EXCEPTION TO THE FREEZE A. Upon 7/26/83 Board approval this is to, request an exception to the freeze to certify and fill the newly established P.I. Clerk-A (Typing Required) position based on emergency operational consequences and direct patient care. B. Upon 7/26/83 Board approval this is to request an exception to the freeze to certify and fill the newly established P.I. Security Guard position based on direct patient care and safety reasons. A-41 3/81 200 William Ray -2- July 13, 1983 This memo gives clear justification for approval of both requests. If you have any questions, feel free to contact me at extension 4154. , Thank you. AJ:jb cc: C. L. VanMarter Judi Sizemore Sue Beadle 201 POSITION ADJUSTMENT REQUEST7 No. - 4 '] Date: 7/11/83 iF Dept. No./ �'�. 1� � t u Copers Department Health services/Medical Budget Unit No. 540 Orgi 6518 Agency No. 54 Care ��" o4 Action Requested: R Adjust Social Worker position hours as attached details. CIVIL Proposed Effective Date: 7/27/83 Explain why adjustment is needed: To accomplish establishment of full time position to increase placement efforts of long-term care patients. i I Classification Questionnaire attached: Yes [] No Estimated cost of adjustment: $ J ! Cost is within department's budget: Yes 0 No If not within budget, use reverse side to explain how costs are to befunded. Department must initiate necessary appropriation adjustment. Ray Philbin Use additional sheets for further explanations or comments. : Personnel S ices Assistant' for Department Head Personnel Department Recommendation Date: 7— /9-? - Increase hours of Medical Social Worker position #54-1272 fr9m 24/40 to 40/40, Salary Level W5, 059 (1476-2035) ; Reduce the hours of Medical Social Worker popition #54-794 from 40/40 to 32/40, Salary Level W8 430 (1630-2035) ; Reallocate Social Worker I'II positio-n #54-1273, -Salary Level H2 307 (1675-2036) to Medical Social Worker "B" -level and reduce the hours from 20/40 to 12/40, Salary Level W5 059 (1476-2035). Amend Resolution 71/17 establishing positions and resolutions allocating .classes to the Basic/Exempt Salary Schedule, as described above. Effective: Cg day following Board action. Date 401ec 4rf Personnel County Administrator Recommendation Date: Approve Recommendation of Director of Personnel O Disapprove Recommendation of Director of Personnel ES Other: for County Administrator Board of Supervisors Action 2 g 1983 Adjustment APPROVED/R+8* Ptftft on JUL J.R. Olss n, County Clerk Date: JUL 2 61983 8 APPROVAL OF THIS ADJUSTMENT CONSTITUTES A PERSONNEL/SALARY RESOLUTION AMENDMENT. M347 6/82 202 ' • � 3v c� POSITION ADJUSTMENT REQUEST No. 1.305- Date: 3DsDate: 7/18/83 Dept. No./ 0540-6900 Copers Department Health Services/0 of D BudgetRynit;_No. Org. No. 6555 Agency No. 54_— PER50i: :EL .: ..;7i Action Requested: Add one (1) 40/40 Secretary positionn cost center 6555; cancel Health Care Counselor IIS - ROUTINE Proposed Effective Date: 7/27/83 Explain why adjustment is needed: To provide Secretarial support services to the Unit Director. I f Classification Questionnaire attached: Yes [] No x0 Estimated cost of adjustment: $ Cost is within department's budget: Yes Ox No (] If not within budget, use reverse side to explain how costs are to be funded. Department must initiate necessary appropriation adjustment. Andrea Jackson Use additional sheets for further explanations or comments. Personnel Services Assistant for Department Head Personnel Department Recommendation Date: 7-/9 -9-3 Add one 40/40 Secretary position, Salary Level B8 167 (1164-1770) ; cancel Health Care Counsellor II 40/40 position #54-1223, Salary Level H2 170 (1461-1776). Amend Resolution 71/17 establishing positions and resolutions allocating classes to the Basic/Exempt Salary Schedule, as described above. Effective: W day following Board action. \ DJ Date for Direc o Personnel County Administrator Recommendation Date: �1VOL Approve Recommendation of Director of Personnel O Disapprove Recommendation of Director of Personnel D Other: or County Administrator Board of Supervisors Action JUL 2 6191)3 Adjustment APPROVED on J.R. Olss.9n, County Clerk Date: UUL 2 6 b83 By: APPROVAL OF THIS ADJUSTMENT CONSTITUTES A PERSONNEL/SALARY RESOLUTION AMENDMENT. M3 7 6/82 203 4 ` r POSITION ADJUSTMENT REQUEST No. 23 b 15 Date: 7/11/83 De ft.L-NP/r j V E, [` Copers Department Health Services/Manage- Budget llnit"No. 540 Org. No. 6466 Agency No. 54 ment & Administration '1 ( 03 A 1 3 rr Action Requested: annm : Reduce the ka)l o� Mental Health Treatment Specialist Position 54-1731 (Marilyn Lane) from 40/40 to (1) 20/40 Mental Health Treatment Specialist "B" level position. V7� Proposed Effective Date: x/18` Explain why adjustment is needed: To adjust staffing in Conservatorship/Guardianship Unit and facilitate return of employee from LOA (see 7/7/83 memo attached) . Classification Questionnaire attached: Yes [] No 0 As per class specs Estimated cost of adjustment: $ .0 Cost is within department's budget: Yes 0 No ❑ offset If not within budget use reverse side to explain how costs are to be funded. Department must initiate necessary appropriation adjustment. Ray Philbin;� r: Use additional sheets for further explanations or comments. Personnel Serdices Assistant' for Department Head Personnel Department Recommendation Date: 7-/2 Reduce the hours of Mental Health TreatmenSpecialist position #54-1731 from 40/40 to 20/40,..Salary Level V5 326. (1364-1746); classify one 20/40 Mental Health Treatment Specialist "B-" level position, Salary Level V5 326 (1364-1746). Amend Resolution 71/17 establishing positions and resolutions allocating classes to the Basic/Exempt Salary Schedule, as described above. Effective: p day following Board action. gi x- r - P3 A211ri-6 `k Date or Dir;-6607JFerionnel County Administrator Recommendation Date: Approve Recommendation of Director of Personnel D Disapprove Recommendation of Director of Personnel D Other: for County Administrator Board of Supervisors Action \ Adjustment APPROVE Dt9'MM41RO"O on JUL 2 6 1983 J.R. Olsso -County Clerk Date: JUL 2 6 19gi By`; YG� D APPROVAL OF THIS ADJUSTMENT CONSTITUTES A PERSONNEL/SALARY RESOLUTION AMENDMENT. M347 6/82 204 POSITION ADJUSTMENT REQUEST No. 3C)¢, Date: 7/8/83 Dept. No./ (. y' Copers Department Health Services/Public Budget UniULN 0 '54 Fr6 No, 5816 Agency No. 54 Action Requested: ROUTINE; eClassify one (1) Public HAA hslt�ogmst position, cancel Home Economist position 54-1845. EFc'VjC n __ Proposed Effective Date: 7/27/83 Explain why adjustment is needed: To augment services in the Sexually Transmitted Disease Pro- gram at the Richmond Health Clinic (see attached memo) , xfx�ai�� attached: Yes ® No Description of duties Estimated cost of adjustment $ 438/month Cost is within department's budget: Yes No (] If not within budget, use reverse side to explain how costs are to be funded. Department must initiate necessary appropriation adjustment. Ray Philbin Use additional sheets for further explanations or comments. Personnel S ices Assistant T1or Department Head Personnel Department Recommendation Date: 7-/9 -,Y 3 Classify one Public Health Epidemiologist position, Salary Level H2 381 (1804-2192) ; cancel Home Economist position #54-1845, Salary Level H2 158 (1443-1754). Amend Resolution 71/17 establishing positions and resolutions allocating classes to the Basic/Exempt Salary Schedule, as described above. Effective: day following Board action. O Date fogDirecto 4frsonnel County Administrator Recommendation Date: 02 0&3 Approve Recommendation of Director of Personnel ❑ Disapprove Recommendation of Director of Personnel 0 Other: for County Administrator Board of Supervisors Action ,V� 2 s 1983 Adjustment APPROVED/Dk6AFfftWFED on J.R. Olsso , County Clerk Date: JUL 2 61983 By: � APPROVAL OF THIS ADJUSTMENT CONSTITUTES A PERSONNEL/SALARY RESOLUTION AMENDMENT. M347 6/82 205 CONTRA COSTA COUNTY HEALTH SERVICES DEPARTMENT To: C. L. Van Marter Date: July 8, 1983 Assistant County Administrator From: Ray Philbin Subject: PUBLIC HEALTH EPIDEMIOLGIST - Personnel Services Assistant SEXUALLY TRANSMITTED DISEASE PROGRAM On 6/22/83 we submitted a memorandum, P-300, certification document, etc. requesting to establish a new Public Health Microbiologist position at the Richmond Health Center and fill it through an exception to the freeze. The instant request is a companion action and asks to add a Public Health Epidemiologist position (V.D. Investigator) with offset at Richmond to intensify services in the Sexually Transmitted Disease Program. As with the Microbiologist, it is anticipated that patient fees and other revenue generated through these activities will offset the additional cost of this position. An exception. to the freeze is warranted in this case due to the patient care considerations of not providing these services. The purpose of this memo is to request you process this P-300 to the Per- sonnel in time for it to be returned for the cutoff for the 7/26/83 Board Agenda with authorization for an exception to the freeze to fill it upon establishment. Attached find the necessary supporting documents including certification request and a description of duties. RP/pa Attachments CC: Glenn White Richard Harrison Francie Wise Bill Ray A-91 31bl 206 PROPOSED PUBLIC HEALTH EPIDEMIOLOGIST POSITION DESCRIPTION OF DUTIES Under the supervision of a Public Health Program Specialist II (Francie Wise) , performs field investigation and clinical teaching activities in the Sexually Transmitted Disease Program at the Richmond Health Center. Specific duties to include: - Interviewing of V.D. cases to obtain names of sexual contacts. - Finding, interviewing, and referring for care all contacts. - Reporting confirmed V.D. cases as per applicable law. - Giving presentations on V.D. to school groups. t 207 memorandum 1 TO FROM Health Services Personnel Francie Wise STD Program Directo SUBJECT DATE t C3 Addition - new position 7/1/83 An additional Public Health Epidemiologist is required in the Sexually Transmitted Disease Program. With the integration of P. H. STD clinics into the Richmond Health Center, there is a need for a full time P.H. Epidemiologist stationed in RHC while the clinics are in operation, 40 hours per week. To remove an FTE Epidemiologist from. the STD.-staff-would reduce the staffing level below that which is necessary to carry out State mandated functions, as well as functions necessary to pro- tect the health and well being of the county, related to STDs. The addition of this position has been approved by Dr. Leff after an explanation of the program needs. I would appreciate your consideration in this matter. ,FW/3h ��n ✓�C Attachment �FI�F vtN 208 t i3s ✓ F POSITION ADJUSTMENT REQUEST No. 1305-6 Date: 7/13/83 Dept. No./ 0540-6900 Copers Health Services/MC F VE 6572 54 Department Budget Unit NoF_.�Eid�:a Org. No. Agency No. PERS0N!1I _177 ..i;';i,:.. i'i Action Requested: Add one 1) P. I. Clerk - A 1 ve (T ing Re uired) in cost center 6572; cancel Home Health Aide (P. I.) po i- 0J ROUTINE Proposed Effective Date: 7/27/83 Explain why adjustment is needed: To provide needed clerical coverage at the East County Clinics. Classification Questionnaire attached: Yes xn No Estimated cost of adjustment: $ Cost is within department 's budget: Yes 0 No If not within budget, use reverse side to explain how costs are to be funded. Department must initiate necessary appropriation adjustment. Andrea Jackson Use additional sheets for further explanations or comments. Personnel Service sistant for Departmen ead Personnel Department Recommendation Date: 7-/ 7-7-3 Add one P. I. Clerk - A level (Typing Required) , Salary Level H1 747 (959-1166) ; , cancel Home Health Aide P. I. position #54-1937, Salary Level H1 723 (936-1138). I i I i j Amend Resolution 71/17 establishing positions and resolutions allocating classes to the Basic/Exempt Salary Schedule, as described above. Effective: 1@day following Board action. C1 Date gforDirector rsonnel County Administrator Recommendation Date: z v �3 Approve Recommendation of Director of Personnel ❑ Disapprove Recommendation of Director of Personnel L� Other: for County Administrator Board of Supervisors Action JUL 2 61983 Adjustment APPROVED/P*@AFfft&kD on J.R. Olsso County Clerk Date: JUL 2 61983 By: APPROVAL OF THIS ADJUSTMENT CONSTITUTES A PERSONNEL/SALARY RESOLUTION AME DMENT. M347 6/82 209 . � POSITION ADJUSTMENT REQUEST No. Date: Dept. No./ PER,Of;fiE"� " Copers , r. Department Manpower - _ Budget Unit No. 0�T5�•8j�,3���aa �r �o;=,.,.;; Agency No. Action Requested Cancel 1Yvacant positions: Ac�u'n't kk4k f-8158-41;�5'g0� Clerk-ex erienced 58-02; %Man ower Aide 58-41 c5580 (SS3� (1 411) Proposed Effective Date: 7/19/83 Explain why adjustment i.s needed: Positions have been unfilled for in excess of. 6 months, not anticipated to be tilled during ky 83-84 Classification Questionnaire attached: Yes [] No • .yr Estimated cost of adjustment: N/A $ N/A Cost is within department's budget: Yes No If not within budget, use reverse side to explain how costs are to be funded. Department must initiate necessary appropriation adjustment. Use additional sheets for further explanations or comments. for epartment Head Personnel Department Recommendation Date: Cancel -fear vacant positions: Account Clerk II #58-41 , Salary Level H2 005 (1239-1506) ; Clerk - Experienced Level #58-02, Salary Level H1 887 (1103-1341 ) ; X58— 6- Manpower Aide #58-411 , Salary Level H2 134 (1409-1713): c m N rn m C;1 Amend Resolution 71/17 establishing positions and resolutions allocating classes'Zto`_the Basic/Exempt Salary Schedule, as described above. = Effective: gg day following Board action. Cl Date for Dir to f ersonnel County Administrator Recommendation Date: R( Approve Recommendation of Director of Personnel D Disapprove Recommendation of Director of Personnel 0 Other: l�F a for County Administrator Board of Supervisors Action JUL 2 6 1983 Adjustment APPROVED/D�PP�EB on J.R. Olsso County Clerk j Date: JUL 2 613 By: APPROVAL OF THIS ADJUSTMENT CONSTITUTES A PERSONNEL/SALARY RESOLUTION AMENDMENT. M347 6/82 14 JL U 7 TO BOARD OF SUPERVISORS FROM: Arthur C. Miner, Director Contra Department of Manpower Programs Cost DATE: July 26, 1983 C i '•1W1C1 SUBJECT: AUTHORIZING EXECUTION OF CERTAIN MODIFICATIONS TO COUNTY'S FFY 1982-83 COMPREHENSIVE EMPLOYMENT AND TRAINING PLAN (COUNTY #29-815-42) SPECIFIC REQUEST(S) OR RECOMMENDATION(S) A BACKGROUND AND JUSTIFICATION That the Board APPROVE modifications to the County's FFY 1982-83 Comprehensive Employment and Training Plan (CETP) as follows: 1. Provides for certain programmatic and budgetary changes to the consolidated subpart for the Fourth Quarter and to deobligate $180, 000 in FFY 1982-83 program funds for transfer to the new Job Training Partnership Act (JTPA) program and carryout of $70, 000 to be transferred for CETA closeout (Modification #305 for Consolidated Subparts No. 06-3004-32) ; 2. Adjustment to the Administrative Cost Pool Budget to identify the carryover into FFY 1983-84 of $250, 000 for the purposes of CETA closeout; and that the Board Chairman is AUTHORIZED to execute said document, on behalf of the County, for submission to the U.S. Department of Labor, and further, that the Director, Department of-Manpower Programs, is AUTHORIZED to make necessary changes as may be required by the U.S. Department of Labor (DOL) . In response to Department of Labor requirements that CETP consolidated plan subparts be continuously monitored and modified when necessary to ensure they are realistic and achievable, the Department of Manpower Programs has reviewed current program plans and actual performance up through the end of the third quarter (June 30, 1983) . As a result of that review, this modification has been prepared for submission to DOL. In addition, the U.S. Department of Labor has notified the Department of Manpower Programs, via CETA Regional Bulletin (CRB) #18-83, that, since there may be a delay in funds for the JTPA program which begins October 1, 1983, prime sponsors may transfer (by deobligation from FFY 1982-83 program funds ) an amount not to exceed that needed for 30 days of program operations. (These funds are to be in addition to and separate from funds identified for CETA closeout. ) This transfer request must be submitted to DOL no later than August 1, 1983. CONTINUED ON ATTACHMENT! _�_ YES SIGNATURE; ��// RECOMMENDATION OF COUNTY ADMINISTRATOR RECOMMENDATION OF BOARD COMMITTEE APPROVE OTHER SIGNATURE S : ACTION OF 130ARD ON APPROVED AS RECOMMENDED OTHER VOTE OF SUPERVISORS Y 1 HEREBY CERTIFY THAT THIS IS A TRUE /1 UNANIMOUS (ABSENT ) AND CORRECT COPY OF AN ACTION TAKEN AYES: NOES: AND ENTERED ON THE MINUTES OF THE BOARD ABSENT: ABSTAIN: OF SUPERVISORS ON THE DATE SHOWN. cc: County Administrator --ATTESTED " 1:2g /g�? County Auditor-Controller U. S . Department of Labor J• OLS66N, COUNTY CLERK (via Manpower) AND IX OFFICIO CLERK of THE BOARD Manpower BY DE ' 1 " ,R`:tachment to 7/26/83 Board Order EXECUTION OF MODS TO FFY '82-183 CETP The Administrative Cost Pool reflects the proposed carryover of $250, 000 in administrative funds for the purpose of CETA closeout. This modification is in accordance with DOL instructions, via CRB #52-82, and is consistent with Contra Costa County's updated Phasedown/Closeout Plan. These requested actions were reviewed and approved by the Private Industry Council at its meeting of July 18, 1983. -r v 212 /�r THE BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Adopted this Order on July 26 , 1983 , by the following vote: AYES: Supervisors Fanden, McPeak, Torlakson, Schroder . , NOES: None . ABSENT: Supervisor Powers . ABSTAIN: None. SUBJECT: Approval of Medical Specialist Novation Contract 4426-860-2 with Susan A. Bailey, M.D. d The Board having considered the recommendations of the Director, Health Services Department, regarding approval of Novation Contract #26-860-2 with Susan A. Bailey, M.D. for professional services in contractor's medical specialty, IT IS BY THE BOARD ORDERED that said contract is hereby APPROVED and the Chairman is AUTHORIZED to execute the contract as follows: Number: 26-860-2 Department: Health Services - Medical Care Division Contractor: Susan A. Bailey, M.D. Speciality: Surgery (General, Vascular and Thoracic) Term: May 1, 1983 through April 30, 1984 Payment Rate: $ 42.80 per hour of consultation, training services, and/or medical procedures, and two-thirds customary fee for each operative procedure. 1 hereby certify that this is a true and correctcopy of an action taken and entered on the minutes of the Board of SL-pervls s on the date shown. ATTESTED: J.R. OL SON, COUNTY CLERK andexooffiiclo Clerk of the Board Deputy Orig. Dept.: Health Services Dept./CGU cc: County Administrator Auditor-Controller Contractor SH:ta 213 �I fl" ' THE BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Adopted this Order on July 26 , 1983 , by the following vote: AYES: Supervisors Fanden, McPeak, Torlakson, Schroder . NOES: None. ABSENT: Supervisor Powers . ABSTAIN: None. SUBJECT: Approval of Medical Specialist Novation Contract 026-861-2 with Hsiu-Li Cheng, C.N.M. The Board having considered the recommendations of the Director, Health Services Department, regarding approval of Novation Contract 026-861-2 with Hsiu-Li Cheng, C.N.M. for professional services in contractor's medical specialty, IT IS BY THE BOARD ORDERED that said contract is hereby APPROVED and the Chairman is AUTHORIZED to execute the contract as follows: Number: 26-861-2 Department: Health Services - Hospital Division Contractor: Hsiu-Li Cheng, C.N.M. Speciality: Certified Nurse Midwife Term: May 1, 1983 through April 30, 1984 Payment Rate: $ 28.50 per hour of consultation and training services, $235.00 for services at each assigned delivery, but only $150.00 will be paid where an assigned delivery becomes a forcep or caesarean section delivery. 1 hereby certify that this is a true an d correct copy of an action taken and entered on the minutes of the Board of Supervi ors on ho date shown. ATTESTED: 83 J.R. OL So;,4, OUKTY CLER%r and ex officic Clerk of the Board Deputy Orig. Dept.: Health Services Dept./CGU cc: County Administrator Auditor-Controller Contractor SH:to 214 V^ THE BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Adopted this Order on July 26 , 1983 , by the following vote: AYES: Supervisors Fanden , McPeak, Torlakson, Schroder . NOES: None ABSENT: Supervisor Powers . ABSTAIN: None . SUBJECT: Approval of Medical Specialist Novation Contract #26-848-2 with Henry K. Lofgran, Inc. The Board having considered the recommendations of the Director, Health Services Department, regarding approval of Novation Contract #26-848-2 with Henry K. Lofgran, Inc. for professional services in contractor's medical specialty, IT IS BY THE BOARD ORDERED that said contract is hereby APPROVED and the Chairman is AUTHORIZED to execute the contract as follows: Number: 26-848-2 Department: Health Services - Hospital Division Contractor: Henry K. Lofgran, Inc. Speciality: Podiatry Term: May 1, 1983 through April 30, 1984 Payment Rate: $ 21.92 per hour for the provision of consultation, training services, and/or medical procedures, and Medi-Cal Rates for each surgical procedure. 1 hereby certify that this Is a true and correct Copy Of an action taken and entered on the minutes of the Board of Supervi ra on a date shown. ATTESTED: J.R. OL SOW, COUNTY CLERK and ex officlo Clerk of the Board DODO Orig. Dept.: Health Services Dept./CGU cc: County Administrator Auditor-Controller Contractor SH:ta 215 m THE BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Adopted this Order on July 26 , 1983 , by the following vote: AYES: Supervisors Fanden, McPeak, Torlakson, Schroder . NOES: None. ABSENT: Supervisor Powers . ABSTAIN: None. SUBJECT: Approval of Medical Specialist Novation Contract #26-847-2 with Michael S. Baker, M.D. The Board having considered the recommendations of the Director, Health Services Department, regarding approval of Novation Contract #26-847-2 with Michael S. Baker, M.D. for professional services in contractor's medical specialty, IT IS BY THE BOARD ORDERED that said contract is hereby APPROVED and the Chairman is AUTHORIZED to execute the contract as follows: Number: 26-847-2 Department: Health Services — Medical Care Division Contractor: Michael S. Baker, M.D. Speciality-: Surgeon (General, Vascular and Thoracic) Term: May 1, 1983 through April 30, 1984 Payment Rate: $ 42.80 per hour for the provision of consultation, training services, and/or medical procedures. $ 12000 per month for on—call services, and two—thirds customary fee for each operative procedure. 1 hereby certify that this is a true and correct copy of an action taken and entered on the minutes of the Boardof Supervisor on th date shown. ATTESTED: J.R. OLS OFn, CO NTY CLERK and ex officio Clerk of the Board fbf► . Deputy Orig. Dept.: Health Services Dept./CGU cc: County Administrator Auditor—Controller Contractor SH:ta 216 THE BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Adopted this Order on July 26 , 1983 , by the following vote: AYES: Supervisors Fanden, McPeak, Torlakson, Schroder . NOES: None. ABSENT: Surervisor Powers . ABSTAIN: None . SUBJECT: Approval of Medical Specialist Novation Contract #26-841-3 with Carole Hagin, C.N.M. The Board having considered the recommendations of the Director, Health Services Department, regarding approval of Novation Contract #26-841-3 with Carole Hagin, C.N.M. for professional services in contractor's medical specialty, IT IS BY THE BOARD ORDERED that said contract is hereby APPROVED and the Chairman is AUTHORIZED to execute the contract as follows: Number: 26-841-3 Department: Health Services - Hospital Division Contractor: Carole Hagin, C.N.M. Speciality: Certified Nurse Midwife Term: May 1, 1983 through April 30, 1984 Payment Rate: $ 28.50 per hour of consultation and training services, $235.00 for services at each assigned delivery, but only $150.00 will be paid where an assigned delivery becomes a forcep or caesarean section delivery. I hereby certify that this is a true and correct copy of an action taken and entered on the minutes of the Board of Supervis +Jdateshown.ATTESTED:J.R. OLS OTY CLERk and ex officio Clerk of the Board Orig. Dept.: Health Services Dept./CGU Co: County Administrator Auditor-Controller Contractor SH:ta 217 THE BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Adopted this Order on July 26 , 1983 , by the following vote: AYES: Supervisors Fanden, Mcpee,k, Torlakson, Schroder . NOES: None. ABSENT: Supervisor Powers . ABSTAIN: None. SUBJECT: Approval of Medical Specialist Novation Contract #26-823-7 with Walter S. Stuilman, M.D. The Board having considered the recommendations of the Director, Health Services Department, regarding approval of Novation Contract #26-823-7 with Walter S. Stullman, M.D. for professional services in contractor's medical specialty, IT IS BY THE BOARD ORDERED that said contract is hereby APPROVED and the Chairman is AUTHORIZED to execute the contract as follows: Number: 26-823-7 Department: Health Services - Hospital Division Contractor: Walter S. Stullman, M.D. Speciality: Cardiology Term: May 11 1983 through April 30, 1984 Payment Rate: $ 225 per session, defined as the provision of consultation and/or training services and/or the performance of medical procedures. I hereby certify that this is a true and correct copy of an action taken and entered on the ^k:::tes of the Board of Supervis on t e date shown. 1r ATTESTED: J6 1 J.R. OLSSCI, COUNTY CLEAK and ex officio Clerk of the Board Deputy Orig. Dept.: Health Services Dept./CGU cc: County Administrator Auditor-Controller Contractor 218 SH:ta THE BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Adopted this Order on July 26 ,1983 by the following vote: AYES: Supervisors Fanden , McPeak, Torlakson, Schroder . NOES: None . ABSENT: Supervisor Powers . ABSTAIN: None. SUBJECT: Approval of Medical Specialist Novation Contract #26-811-7 with Stephen M. Murphy, M.D. The Board having considered the recommendations of the Director, Health Services Department, regarding approval of Novation Contract #26-811-7 with Stephen M. Murphy, M.D. for professional services in contractor's medical specialty, IT IS BY THE BOARD ORDERED that said contract is hereby APPROVED and the Chairman is AUTHORIZED to execute the contract as follows: Number: 26-811-7 Department: Health Services - Medical Care Division Contractor: Stephen M. Murphy, M.D. Speciality: Plastic Surgery Term: May 1, 1983 through April 30, 1984 Payment Rate: $ 42.80 per hour of consultation and training services, and $100.00 per RVS Unit for each medical procedure. I hereby certify that this is a true and correct copy of an action taken and entered on the minutes of the Board of Supervis rs on the date shown. ATTESTED: 2 G J.R. OLSSON, COUNTY CLERk and ex officio Clerk of the Board Deputy Orig. Dept.: Health Services Dept./CGU CC: County Administrator Auditor-Controller Contractor SH:ta 219 � 3Y THE BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Adopted this Order on July 26 , 1983 , by the following vote: AYES: Supervisors Fanden, McPeak, Torlakson, Schroder . NOES: None. ABSENT: Supervisor Powers . ABSTAIN: None . SUBJECT: Approval of Medical Specialist Novation Contract 4426-856-2 with Diablo Pulmonary Medical Group The Board having considered the recommendations of the Director, Health Services Department, regarding approval of Novation Contract #26-856-2 with Diablo Pulmonary Medical Group for professional services in contractor's medical specialty, IT IS BY THE BOARD ORDERED that said contract is hereby APPROVED and the Chairman is AUTHORIZED to execute the contract as follows: Number: 26-856-2 Department: Health Services - Medical Care Division Contractor: Diablo Pulmonary Medical Group Speciality: Internal Medicine Term: May 1, 1983 through April 30, 1984 Payment Rate: $ 42.80. per hour of consultation and training services, and two-thirds customary fee for each medical procedure. 1 hereby certify that this Is a true and correct copy of an action taken and entered on the minutes of the Boardof Supenis on t date shown. ATTESTED: J.R. OL OPJ, COUNTY CLERk and ex officio Clerk o; the Board b •Deputy Orig. Dept.: Health Services Dept./CGU cc: County Administrator Auditor-Controller Contractor SH:ta 220 39 THE BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Adopted this Order on July 26 , 1983 , by the following vote: AYES: Supervisors Fanden, McPeak, Torlakson, Schroder . NOES: None . ABSENT: Supervisor Powers . ABSTAIN: None. SUBJECT: Contract for Attorney Services - Antioch Unified School - District On recommendation of the County Administrator, IT IS BY THE BOARD ORDERED that the Chair is authorized to sign an agreement between the County and the Antioch Unified School District under the terms of which the County Counsel has provided legal services to the District in connection with proceedings arising out of Patricia Martin/McCaffety v. Antioch Unified School District. 1 hereby certify that this is a true and correct copy of an action taken and entered on the minutes of the Board of Suporvisors on the date shown. ATTESTED: Id [S J.R. O&SONY COUNTY CLERK and ex officio Clerk of the Board Deputy Orig. Dept.: cc: County Administrator County Counsel Contractor 221 YO THE BOARD OF SUPERVISORS CONTRA COSTA COUNTY, CALIFORNIA Adopted this Order on July 26 , 1983 , by the following vote: AYES: Supervisors Faaden , McPealc, Torlakson , Schroder . NOES: None . ABSENT: Supervisor Powers . - SUBJECT: Geologic Services Agreement with the City of El Cerrito The Director of Planning having recommended that the County enter into an agreement with the City of El Cerrito for geologic services to be furnished by the County Planning Department; IT IS BY THE BOARD ORDERED that the Chairman of the Board of Supervisors is authorized to execute the Geologic Services Agreement. 1 hereby certify that this is a true and correct copy of an action token and entered on tho minutes of the Board of Suporviso on the date shown. ATTESTED: J.R. OL. OPJ, C LINTY CLER,i andexofficio Clerk of the Board De" Orig. Dept.: Planning Department Cc: County Administrator Auditor-Controller City of El Cerrito 222 THE BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Adopted this Order on July 26 , 198 3 Ju -, by the following vote: AYES: Supervisors Fanden, McPeak, [Torlakson, Schroder . NOES: None. ABSENT: Supervisor Powers . ABSTAIN: None . SUBJECT: Contract amendment with the State of California for Housing of State Prisoners at the County Rehabilitation Center at Clayton, fiscal 1982-83. The State of California, Department of Corrections, and the County of Contra Costa having in the past contracted for the housing and supervision of state prisoners at the Contra Costa County Detention Facilities; and The Sheriff-Coroner and the County Administrator having recommended that the agreement be continued for 1982-83 fiscal year. IT IS BY THE BOARD ORDERED that the recommendations are APPROVED and that the chairperson of the Board of Supervisors is AUTHORIZED to execute an amendment with the State of California for fiscal 1982-83 to enable the State and County to technically meet the conditions of the contract. I hereby certify that this'.19 a true and correct copy of an action taken and entered on the minutes of the Board of Supervisor on the date shown. ATTESTED: J.R. OLS OPJ, C© NTY CLERK and ex officio Clerk of the Board Deputy Orig. Dept.. Sheriff-Coroner cc: County Auditor-Controller County Administrator State Department of Corrections 223 1 � THE BOARD OF SUPERVISORS CONTRA COSTA COUNTY. CALIFORNIA 'Adopted this Order on July 26, 1983 by the following vote: AYES: Supervisors Fanden, McPeak , Torlakson, Schroder. a NOES: None. ABSENT: Supervisor Powers . SUBJECT: Authorizing Execution of a Lease Commencing July 1, 1983, to The YWCA of Contra Costa County for the Premises at 100 Glacier Drive, Martinez. IT IS BY THE BOARD ORDERED that the Chairman of the Board of Super- visors is AUTHORIZED to execute, on behalf of the County, a Lease commencing July 1, 1983, to The YWCA of Contra Costa County for the premises at 100 Glacier Drive, Martinez, for continued occupancy by The YWCA of Contra Costa County under the terms and conditions as more particularly set forth in said Lease. 1 hereby certify that this is a true and correct copy of an action taken and entered on 'the m!nutes of the Board of Super-03on the dale shovm. ATTESTED: 9 3 J.R. OL v ONN, C;0uM�-TI V C L E R k and ex oNicio Ciark of the Board • Deputy Public Works Department-L/M Or( Dept.: Public Works Accounting (via L/M) 9 Buildings and Grounds (via L/M) cc: County Administrator County Auditor-Controller (via L/M) Lessee (via L/M) 100G1crB018.t7 224 ' M THE BOARD OF SUPERVISORS CONTRA COSTA COUNTY, CALIFORNIA Adopted this Order on July 26 , 1983 by the following vote: AYES: Supervisors Fanden, McPeak, Torlakson, Schroder . NOES: None. ABSENT: Supervisor Powers . SUBJECT: Approval of the Ninth Year (1983-84) Community Development Block Grant Agreement and Reallocation of Funds; City of Pinole. The Board having heard the recommendation of the Director of Planning that it approve the Ninth Year CDBG Program Project Agreement with the City of Pinole implementing Activity 9-11 - Neighborhood Beautification Program with a payment limit of $15,916.62 comprised of $13,000 of Ninth Year Alloca- tion and $2,916.62 carryover from the previous year Activity #8-11 - Neigh- borhood Beautification Program; IT IS BY THE BOARD ORDERED that the above recommendation is approved and that its Chairman is authorized to execute said agreement. 1 hereby certify that this Is a true and correct copy of an action taken and entered on the minutes of the Board of Supervisors on t ie date shown. ATTESTED: 6 9 J.R. OLSSOfN, COUNTY CLERK and ex officio Cleric of the Board Dept Orig. Dept.: Planning CC: County Administrator County Counsel Auditor-Controller Contractor 225 THE BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Adopted this Order on July 26 , 1983 , by the following vote: AYES: Supervisors Fanden, McPeak, Torlakson, Schroder . NOES: None. ABSENT: Supervisor Powers . ABSTAIN: None. SUBJECT: Agreement with Volunteer Bureau of Contra Costa County IT IS BY THE BOARD ORDERED that its Chair is AUTHORIZED: to execute an agreement between the county and the Volunteer Bureau of Contra Costa County to provide a Court Referral Program Job Placement Service for persons assigned volunteer community service as a sentencing alternative by the municipal courts within Contra Costa County; said agreement to be effective for the period July 1, 1983 through June 30, 1984 at a cost not to exceed $27 ,000, and to be administered by the Delta Judicial District. 1 hereby certify that thle Is a true and correct copy of an action taken and entered on the minutcc or -:,a Board of Supervisor on the date shown. ATTESTED: ��? J.R. OLS -- ; co'UNTY CLEF:• and ex officio Cierk of the Boa; Deputy Orig. Dept.: Administrator cc: Clerk Administrators--Bay, Mt. Diablo, and Delta Municipal Courts Auditor-Controller ' Volunteer Bureau of Contra Costa County 226 rv+ THE BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Adopted this Order on July 26 , 1953 , by the following vote: AYES: Supervisors . Fanden , McPeah, Torlakson, Schroder . NOES: None. ABSENT: Supervisor Powers . ABSTAIN: None. SUBJECT: Approval of Contract #26-130 with Judith McEnroe (dba On-Call Therapists) The Board having considered the recommendations of the Director, Health Services Department, regarding approval of Contract #26-130 with Judith McEnroe (dba On-Call Therapists) for temporary licensed therapy personnel to assist County Hospital and clinics during peak loads, temporary absences and emergency situations, IT IS BY THE BOARD ORDERED that said contract is hereby APPROVED and the Chairman is AUTHORIZED to execute the contract as follows: Number: 26-130 Department: Health Services - Medical Care Division Contractor: Judith McEnroe (dba On-Call Therapists) Term: July 27, 1983 through November 24, 1983 Payment Limit: $10,000 1 hereby certify that this Is a true and correct copy of an action taken and entered on the minutes of the Board of Supeon the date shown. rviso ATTESTED: N , HL� J.R. OLSSCN, COUNTY CLERk and ex officio Clerk of the Board Ce" Orig. Dept.: CC: Health Services Dept./CGU County Administrator Auditor-Controller Contractor DG:sh 227 THE BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Adopted this Order on Jul}: 26 , 1983 , by the following vote: AYES: Supervisors Fanden , McPeak, Torlakson, Schroder . NOES: None. ABSENT: Supervisor Powers . ABSTAIN: None. SUBJECT: Approval of Contract Amendment 4123-017-2 with Amherst Associates, Inc. The Board on August 24, 1982, having authorized execution of Contract 4123-017 and on January 25, 1983, having authorized execution of Contract Amendment Agreement -#23-017-1 with Amherst Associates, Inc. for data processing services for the Management and Administration Division of the County's Health Services Department, and The Board having considered the recommendations of the Director, Health Services Department, regarding approval of Contract Amendment 4123-017-2 with Amherst Associates, Inc. to provide additional services and increase the payment limit, IT IS BY THE BOARD ORDERED that said contract amendment is hereby APPROVED and that the Board Chairman is AUTHORIZED to execute said amendment as follows: Number: 23-017-2 Department: Health Services - Management and Administration Division Contractor: Amherst Associates, Inc. Effective Date of Amendment: July 27, 1983 (no change in original contract term: September 1, 1982 through August 31, 1983) Payment Limit Increase: $20,000 (from $50,000 to a new total amount of $709000) 1 hereby certify that this Is a true and correct copy of an action taken and entered on the minutes of the Board of Superviso on th date shown. ATTESTED: dS 3 J.R. OLS N, COUNTY CLERk and ex officio Clerk of the Board Orig. Dept.: Health Services Dept./CGU CC: County Administrator Auditor-Controller Contractor 228 EAS:ta THE BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Adopted this Order on July 26 , 1983 , by the following vote: AYES: Supervisors Fanden, _McPeak, Torlakson, Schroder . NOES: None. ABSENT: Supervisor Powers , ABSTAIN: None . SUBJECT: Approval of Contract #26-131 with Nathan A. Gilbert, Esq. and Barry Wally The Board having considered the recommendations of the Director, Health Services Department, regarding approval of Contract #26-131 with Nathan A. Gilbert, Esq. and Barry Wally for consultation and technical assistance with regard to recoupment of medical care costs under worker's compensation laws, IT IS BY THE BOARD ORDERED that said contract is hereby APPROVED and the Chairman is AUTHORIZED to execute the contract as follows: Number: 26-131 Department: Health Services - Medical Care Division Contractor: NATHAN A. GILBERT, ESQ. and BARRY WALLY Term: August 1, 1983 through June 30, 1984 Payment Limit: Not applicable - Contactor will receive an amount equal to 25% of all money recovered through his activities under this contract. 1 hereby certify that this Is a true and correct copy of an action taken and entered on the minutes of the Board of Supams a on the date shown. ATTESTED: J.R. OL SONC t1TtTY CLERK and ex officio Clerk of the Board e DepullY Orig. Dept.: Health Services Dept./CGU CC: County Administrator Auditor-Controller Contractor EAS:ta 229 l� TO: BOARD OF SUPERVISORS FROM: Arthur Miner, Director I./lJl ltra Department of Manpower Programs Costa DATE: July 26. 1983 Coit, SUBJECT: AUTHORIZING EXECUTION OF TWO (2) FFY 1982-1983 TITLE VII CONTRACTS WITH INDUSTRY EDUCATION COUNCIL OF CALIFORNIA AND ACALANES UNION HIGH SCHOOL DISTRICT SPECIFIC REQUEST(S) OR RECOMMENDATION(S) & BACKGROUND AND JUSTIFICATION That the Board AUTHORIZE the Director , Department of Manpower Programs , to execute, on behalf of the County, standard form CETA Title VII contracts with the following Contractors , subject to approval by County Counsel as to legal form, and under terms and conditions as more particularly set forth in said contracts : Term of Contract Title VII Contractors Service Program Contract Payment Limit l. - Industry Education Food Handlers/ 6/20/83- Council of Production 9/30/83 $9 , 234. 00 California (#19-7028-0) 2. Acalanes Union Disabled Youth 6/20/83- $9 , 660 . 00 High School for Private 01/9/83 District Sector (#19-7029-0) Employment On June 14, 1983 , the Board authorized the Director, Department of Manpower Programs , to conduct contract negotiations with Industry Education Council of California and with Acalanes Union High School District for implementation of the activities of the service programs . These contracts will provide classroom training and on-the-job training (OJT) services to approximately eighteen (18) of the County' s CETA-eligible Title VII participants . Contract negotiations have been completed with these Contractors . Authorization for the Manpower Programs Director to execute these contracts is necessary in order to expedite the payments to these Contractors for services rendered to date under the terms of the contracts . Funding for these contracts is 100 percent federal funds . CONTINUED ON ATTACHMENT: _ YES SIGNATURE: "h� RECOMMENDATION OF COUNTY ADMINISTRATOR RECOMMENDATION OF BOARD COMMITTEE APPROVE _ OTHER IItIl SIGNATURE S : X24 I►CTION OF BOARD ON APPROVED AS RECOMMENDED OTHER /OTE OF SUPERVISORS 1 HEREBY CERTIFY THAT THIS IS A TRUE X UNANIMOUS (ABSENT ) AND CORRECT COPY OF AN ACTION TAKEN AYES: NOES. AND ENTERED ON THE MINUTES OF THE BOARD ABSENT: ABSTAIN: OF SUPERVISORS ON THE DATE SHOWN. :c: County Administrator ATTESTED 1 ' 0 G s Auditor-Controller J.R. OLSSO , COU Y CLERK Manpower Programs AND EX OFFICIO CLERK OF THE BOARD Contractors BY %���� ,DEPUTY 2 3 0 THE BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Adopted this Order on July 26 , 1983 by the following vote: , AYES: Supervisors Fanden, McPeak, Torlakson, Schroder . NOES: No-ie. ABSENT: Supervisor Powers . ABSTAIN: None. SUBJECT: APPROVAL OF AMENDMENT TO THE NINTH YEAR (1983-84) COMMUNITY DEVELOPMENT BLOCK GRANT PROGRAM PROJECT AGREEMENT AND REALLOCATION OF CARRYOVER FUNDS WITH THE HOUSING ALLIANCE OF CONTRA COSTA COUNTY, ACTIVITY #9-7; ORIGINAL AGREEMENT APPROVED ON MAY 24, 1983 The Board having heard the recommendation of the Director of Planning that it approves first amendment to the Ninth Year Agreement which incorporates $11,492.70 in carryover funds from the previous program years activity #8-6 Housing Counseling increasing the payment limit from $85,000 to $969492.70; IT IS BY THE BOARD ORDERED that the above recommendation is approved and that its Chairman is authorized to execute said amendment. I hereby certify that this is a true and correctcopyof an action taken and entered on the minutes of the Board of Supervl s on the date shown. ATTESTED: a J.R. OLSSON, COUNTY CLERk and ex officio Clerk of the Board Deputy Orig. Dept.: Planning Department CC: County Administrator Auditor-Controller County Counsel Contractor 231 /- SD ro: BOARD OF SUPERV&®RS U "Rat: Arthur C. Miner, Director Cwtrd Department of Manpower Programs Costa )ATE: July 26, 1983 �JvW`�"LQ'•7 SUBJECT: AUTHORIZING EXECUTION OF CONTRACT WITH MICCICHE AND ASSOCIATES (COUNTY #19-9013-0) SPECIFIC REQUEST(S) OR RECOMMENDATION(S) & BACKGROUND AND JUSTIFICATION That the Board AUTHORIZE the Director, Department of Manpower Programs to execute, on behalf of the County, standard form Contract #19-9013-0 with the consultant firm, Micciche and Associates, to develop and deliver a Comprehensive Economic Development Strategy(ies ) for Contra Costa County, for the term beginning July 1, 1983 and ending September 30, 1983 with a total contract payment limit not to exceed $50, 000, subject to approval by County Counsel as to legal form, and under terms and conditions as more particularly set forth in said Contract . On June 28, 1983, the Board authorized contract negotiations with Micciche and Associates ; these negotiations have been completed. The herein requested action is necessary in order to permit Contractor to meet its initial expenses for work provided under this contract. Funds for this contract are 100 percent CETA Title VII Private Sector Initiative Program federal funds . ONTINUED ON ATTACHMENT: _ YES SIGNATURE: RECOMMENDATION OF COUNTY ADMINISTRATOR RECOMMENDATION OF BOARD COMMITTEE APPROVE OTHER 7 / I 1 GNATURE S : CTION OF BOARD ON AM APPROVED AS RECOMMENDED OTHER _ OTE OF SUPERVISORS 1 HEREBY CERTIFY THAT THIS IS A TRUE (� UNANIMOUS (ABSENT _) AND CORRECT COPY OF AN ACTION TAKEN AYES: NOES. AND ENTERED ON THE MINUTES OF THE BOARD ABSENT: ABSTAIN: OF SUPERVISORS ON THE DATE SHOWN.. - County Administrator ATTESTED LL../ 'a I M'� Auditor-Controller J. OLSSCA,—COUNTY CLERK Finance Committee AND EX OFFICIO CLERK OF THE BOARD Manpower Department Q;.?2 . BY Contractor L' �if��� DEPUTY THE BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Adopted this Order on July 26 , 1983 , by the following vote: AYES: Supervisors Fanden, McPeak, Torlakson, Schroder . NOES: None. ABSENT: Supervisor Powers . ABSTAIN: None. SUBJECT: APPROVAL OF AMENDMENT AND REALLOCATION OF FUNDS, EIGHTH YEAR (1982-83) COMMUNITY DEVELOPMENT BLOCK GRANT AGREE- MENT, CITY OF PLEASANT HILI; ORIGINAL AGREEMENT EXECUTED AUGUST 199 1982 The Board having heard the recommendation of the Director of Planning that it approve the first amendment to the Eighth Year CDBG agreement in- corporating $15,231 from Contingency and $50,000 from Activity 9-21 Street Improvements increasing the payment limit from $278,978.56 to $344,209.56; IT IS BY THE BOARD ORDERED that the above recommendation is approved and that the Chairman is authorized to execute said agreement. 1 hereby certify that this Is a true and correct copy of an action taken and entered on the minutes of the Board of Supervisors on the date shown. ATTESTED: 6 J.R. OL OOv, COU; i Y CLERK and ex officlo Clerk of the Board Deputy Orig. Dept.: Planning Department cc: County Administrator Auditor-Controller County Counsel Contractor 233 >i o - TO: BOARD OF SUPERVISORS / $� FROM: M.G. Wingett ,." -"tra Costa 15ATE: July 14, 1983 Cuar-v SUBJECT: Authorize relief of cash shortages for the Delta, Mt. Diablo and Walnut Creek Municipal Court Districts. DECIFIC RECIUEST(S ( OR RECOI4AENDATION(S ) & BACKGROUND Ato JUSTIFICATION RECOMMENDATION It is recommended that the Board of Supervisors grant the following reliefof cash shortages: $5. 00 for the Delta Municipal Court District; $5.00 for the Mt. Diablo Municipal Court District; and $23. 00 for the - Walnut Creek/Danville Municipal Court District, as recommended by the - Auditor Controller and District Attorney' s offices pursuant to Government Code Section 29390 . BACKGROUND The Delta Municipal Court District requests a relief of cash shortage in the amount of $5. 00 . This shortage was discovered on March 18 , 1983. The Mt. Diablo Municipal Court District requests a relief of cash shortage in the amount of $5. 00, discovered on May 17, 1983. The Walnut Creek/Danville Municipal Court District requests a relief of cash shortage in the total amount of $23.00. The shortages of $5. 00, $3 . 00, $5. 00 and $10. 00 were discovered from February 22, 1983-March 22, 1983. As per Government Code Section 29390, the Auditor Controller and District Attorney' s offices have investigated this matter and it is their recommendation that the Board of Supervisors grant a relief of cash shortage in the amounts specified to the Delta, Mt. Diablo, and Walnut Creek/Danville Municipal Court Districts. -ONTINUCO ON ATT^C.NENT; _- YCS SIGNATURE: _Xp. RCCON•+r.rIO.T 101, OF COUNTV ADMINISTRATOR rICCOMMCNDATION OF DOwRD CONMITTI:C . O)TH j I rNATIJn 1151'. ( ll i "' / .c . loll of 110.110 ON . Arr•noV Cn A5 uEt oMM urncn oTNl:u VUTC or SI)1•I:NVIS(V/y I /CnEBY CERTIFY T14AT THIS IS A TRUE X UNANII.IQJS (ABSENT .�/ AND COnnCCT COPY Or AN ACTION TAKEN AYE.`.:' _ N7CS . AND ENTCnCD CIN TIC MIMJTES Or T1fr IWDAnD AULCrIT: -_ ABSTAIN:-______ Or SUr•Croviso s ON TPC DATC SIOWN. CC Delta Municipal Court District ATTCSTCD J . OL S, 4• COUNTY CLERK Mt. Diablo Municipal Court District AP CX Orr IC IO CLCI,K or TI4E BOARD Walnut Creek/Danville Municipal Court District Auditor Controller District Attorney BY . .---- ..._.._.__._._ DCry TY 234 THE BOARD OF SUPERVISORS CONTRA COSTA COUNTY, CALIFORNIA July 26 , 1983by the following vote; 'Adopted this Order on , AYES: Supervisors Fander_, McPeak, Torlakson, Schroder . NOES: None . ABSENT: Supervisor Pokers . _ SUBJECT: Request by Oakley Union School District for Park Dedication Funds The Director of Planning having recommended that an additional $15,218.47 be released from park dedication funds to the Oakley Union School District for architectural fees in connection with the development of Gehringer Park from Account 100303020 and; IT IS BY THE BOARD ORDERED that the aforesaid recommendation is approved. 1 hereby certify that this Is a true and correct copyot an action taken and entered on the minutes of the Board of Supervi: 4on , datesho+an.ATTESTED:J.R. OL,,SCiTY CLERii and ex officio Clerk W the Board Deputy Orig. Dept.: Planning Department cc: County Administrator Auditor-Controller Oakley Union School District 235 0 To: BOARD OF SUPERVISORS . FROM ; M. G. Wingett, \.JLJI itra County Administrator Cost DATE: July 26, 1983 Coity SUBJECT: Increase Public Works Department Revolving Fund SPECIFIC REQUEST(S) OR RECOMMENDATION(S) Q BACKGROUND AND JUSTIFICATION SPECIFIC REQUEST: Approve increase in Public Works Department Revolving Fund from 305 to $405 . BACKGROUND: The Public Works Director requested that the revolving fund for his department be increased by $100 in order to meet the increased need for mail service. The request was reviewed and recommended for approval by the County Auditor-Controller. CONTINUED ON ATTACHMENT: YES SIGNATURE' X RECOMMENDATION OF COUNTY ADMINISTRATOR RECOMMENDA ION BOARD COMMITTEE X_ APPROVE OTHER SIGNATURE I S Z ACTION OF BOARD ON APPROVED AS RECOMMENDED OTHER VOTE OF SUPERVISORS i HEREBY CERTIFY THAT THIS IS A TRUE /1 UNANIMOUS (ABSENT i/ ) AND CORRECT COPY OF AN ACTION TAKEN Ti AYES: NOES: AND ENTERED ON THE MINUTES OF THE BOARD ABSENT: ABSTAIN: OF SUPERVISORS ON THE DATE SHAWN. cc: County Administrator ATTESTED ``�� �6 Auditor-Controller J. OLs , COUNTY CLERK Public Works Department AND EX OFFICIO CLERK OF THE BOARD �n 236 DEPUTY M THE BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Adopted this Order on July-26, 1983___, by the following vote: AYES: Supervisors Fanden, McPeak, Torlak.on , Schroder. NOES: None . ABSENT- Superviros Powers . ABSTAIN: None . ; SUBJECT: County Contribution Toward Health Plan Premium Increases for August 1983 Only This Board, having been advised that Health Plan Premium Increases for the ensuing year become effective August 1, 1983, IT IS BY THE BOARD I ORDERED that for the month of August 1983 o0y, the County will contribute an amount necessary to pay the increases in the premiums provided however that the maximum increase in the County contribution shall be seven dollars and thirty cents ($7.30) for a single subscriber and fifteen dollars and sixty cents ($15.60) for a family subscriber. These additional contributions for the month of August, 1983 only are authorized for management and unrepresented employees, retirees and for employees represented by the following employee organizations, assuming said organizations agree to this Board Order: California Nurses Association Contra Costa County Appraiser's Association Contra Costa County Employees Association, Local 1 Physicians Union, Local 683 Professional & Technical Engineers, AFSCME, Local 512 Social Services Union, SEIU, Local 535 United Clerical Employees, AFSCME, Local 2700 Western Council of Engineers 1 hereby certify that this Is a true and correct copy of Nth action taken and entered on the minutes of the Board o1 SupervisorA on the date shcHn. ATTESTED: / 8 3 J.R. OL5 Ofd, C06NTY CLERvi and ex officio Clerk of the Board Deptiyr cc: Employee Organizations County Counsel Director of Personnel County Administrator Auditor-Controller 237 THE BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA July 26 , 1983 b the following vote: Adopted this Order on y g AYES: Supervisors Faoden , McPeak, Torlakson, Schroder . NOES: None . ABSENT: Supervisor Powers . ABSTAIN: None. SUBJECT: Authorizing Increase in the Revolving Fund for the Auditor-Controller On the request of the County Auditor-Controller and the recommendation of the County Administrator, it is by the Board ordered that an increase from $75.00 to $100.00 in the revolving fund of the Auditor-Controller is AUTHORIZED. 1 hereby Certify that this Is a true and correct copy of an action taken and entered on the minutes of the Board of Supernlsor on the date shown. ATTESTED: �, 3 J.R. OL Cid, C LINTY CLERi: and ex officio Clerkorthe Board Orig. Dept.: Auditor-Controller cc: County Administrator 238 THE BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Adopted this Order on July 26 , 1983 , by the following vote: AYES: Supervisors Fanden , McPeak, Torlakson, Schroder . NOES: None . ABSENT: Supervisor Powers . ABSTAIN: None. SUBJECT: Amendment of Board Order dated May 24, 1983 for Emergency Residential Care Placement Agreements 'The Board on May 24, 1983, having authorized agreements with three residential care facility operators under the County's Continuing Care Program effective May 24, 1983, and The Board having considered the recommendations of the Director, Health Services Department, regarding deletion of reference to one Emergency Residential Care Placement Agreement in said Board Order, IT IS BY THE BOARD ORDERED that reference to the agreement listed below in the Board Order dated May 24, 1983 is hereby DELETED: 24-086-94 Araceli L. Posadas (dba Araceli's Care Home) 1 hereby certify that thla Ina true and coneeteopy of an action taken and entered on the minutes of the Board of Superviso on t e date shown. ATTESTED: -� J.R. XStOhi, COUNTY CLERK and ex officio Clerk c'r the Board d1 • Deputy Orig. Dept.: Health Services Dept./CGU cc: County Administrator Auditor-Controller . Contractor SH:ta 239 THE BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Adopted this Order on July 26 , 1983 , by the following vote: AYES: Supervisors Fanden, McPeak, Torlakson, Schroder . NOES: None. ABSENT: Supervisor Powers . ABSTAIN: None. ' SUBJECT: APPROVAL OF PAYMENTS FOR ATTORNEY FEES - SSI CLAIMANT CONTINGENCY SERVICES (Reference Numbers 21-001-43, 21-001,44, ,.21-001-450 21-001-460 21-001-47) The Welfare Director having advised the Board regarding attorney fees for Supplemental Security Income (SSI) recoveries and recommending that payment be made to four attorneys for contingency services in representation of General Assistance clients granted retroactive Supplemental Security Income (SSI) benefits, resulting in County lien recovery for General Assistance payments; IT IS BY THE BOARD ORDERED that the Auditor-Controller is directed to pay upon demand the following pro rata share of contingency fees: Payees Payment Amount Sandra Horwich $ 219.00 233.00 684.00 Total: $ 1,136.00 D. Jean Hastings 186.00 Mary Burke 673.25 Mary Burke 411.50 Julie Steinbock 787.00 r I hereby certify that this is a true and correct copy of an action taken and entered on the minutes of the Board of Supervlsors n the date shown. ATTESTED- J.R. OLS C4, Cc&N--Y CLF.R- and ex officio Clerk of the Board Orig. Dept.: Social Service Department (Attn: Contracts Unit) cc: Claimant County Administrator Auditor-Controller 240 THE BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA July 26 , 1983 Adopted this Order on , by the following vote: AYES: Supervisors Fanden, McPeak, Torlakson, Schroder: NOES: None . ABSENT: Supervisor Powers . ABSTAIN: None. SUBJECT: Travel Authorization The Director, Community Services Department having advised the Board of a workshop sponsored by the San Diego Department of Education for the purpose of- training staff and parent teams to become trainees of parents and staff working with handicapped children; and The emphasis of the County Head Start Program is to train local agency personnel and parents to provide training services to Head Start staff and families of handicapped children; and Federal Head Start Program funds are authorized and available to secure training: IT IS BY THE BOARD ORDERED that Gloria Tays, Parent Coordinator for the Pittsburg First Baptist Church Head Start Program and Linda Anderson, Parent Representative of the United Council of Spanish Speaking Organizations Head Start Program are AUTHORIZED to attend the staff-parent "Connections" Workshop in San Diego, California, July 31, 1983 - August 5, 1983. 1 hereby certify that this is a true and cortect copy of an action taken and entered on the minules of the Board of Supgrvia E ca ATTESTED: J.R. OL .>CIV; C UNTY CLLR.°: and ex efi°ic o C6erk of the Board By .lJ' Deputy Orig. Dept.: Community. Services cc: County Administrator County Auditor-Controller 241 �G CJ THE BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Adopted this Order on July 26 , 1983 , by the following vote: AYES: Supervisors Fanden, hfcPeak , Torlakson , Schroder. NOES: None . ABSENT: Supervisor Powers . ABSTAIN: None . SUBJECT: Administrative services Contract Between the Brentwood and Eastern Fire Protection District. The County Administrator having recommended the execution of a contract for the provision of administrative services to the Brentwood Fire Protection District by the Eastern Fire Protection District at a cost of $850. 00 per month for the 1983-1984 fiscal year. IT IS BY THE BOARD ORDERED that the Chairman of the Board of Supervisors is authorized to execute subject contract on behalf of said fire protection districts . 1 hereby codify that this Is a true and correct copy of an action taken and entered on the minutes of the Board of Supervisor on t e date shown. G ATTESTED: J.R. OL SON, COUNTY CLERi and ex officio Clerk of the Board or Deputy Orifi. Dept.: County Administrator cc: Brentwood Fire Protection District Eastern Fire Protection District Auditor-Controller 242 THE BOARD OF COMMISSIONERS, HOUSING AUTHORITY OF THE COUNTY OF CONTRA COSTA RESOLUTION NO. 3402 ESTABLISHING A GOAL FOR MINORITY BUSINESS ENTERPRISES WHEREAS, in its Public Housing Comprehensive Improvement Assistance Program Handbook, 7485.1 REV-1, the Department of Housing and Urban Development requires that each Housing Authority must, as part of its Affirmative Action program, provide every feasible opportunity for minority business enterprises to participate in bidding for modernization work; and, WHEREAS, Paragraph 6-2 of the Public Housing Comprehensive Improvement Assistance Program Handbook requires that each Housing Authority with modernization contracts to be awarded during the Federal Fiscal Year shall establish the goal of awarding at least 20 percent of the dollar value of the total of contracts with construction contractors, architects/engineers , consultants (for both physical and management improvements) and purchases under the HUD Consolidated Supply Program: NOW, THEREFORE BE IT RESOLVED, that the Board of Commissioners of the Housing Authority of the County of Contra Costa does hereby establish the goal of awarding at least 20 percent of the dollar value of the total of modernization contracts to be awarded during the current and future Federal Fiscal Years to Minority Business Enterprises. Adopted on 7-26-83 -_by the following vote of the Commissioners: AYES: Comnissioners Fanden, flePeak, Torlakson, SCtIfOCIE,r . NOES: None. ABSENT: Commissioner Powers . ABSTAIN: None. CC : Contra Costa County Housing Authority County Counsel County Administrator 243 HOUSING AUTHORITY o. +wc COUNTY OF CONTRA COSTA 1111 ESTUDILLO STREET P.O. SOX 2196 14151 226.5110 MARTINEZ, CALIFORNIA 94561 CERTIFICATE I , Perfecto Villarreal , the duly appointed, qualified and acting Secretary/Treasurer - Executive Director of the Housing Authority of the County of Contra Costa, do hereby certify that the attached extract from the Minutes of the Regular Session of the Board of Commissioners of said Authority, held on July 26 , 1983 is a true and correct copy of the original Minutes of said meeting on file and of record insofar as said original Minutes relate to the matters set forth in said attached extract. IN WITNESS WHEREOF, I have hereunto set my hand and the seal of said Authority this 26th day of July 1983 (SEAL) erfe to Villarreal , Secretary 208-jt-82 244 ,r t . THE BOARD OF COMMISSIONERS, HOUSING AUTHORITY OF THE COUNTY OF CONTRA COSTA RESOLUTION NO. 3400 AUTHORIZING COLLECTION LOSS WRITE-OFF WHEREAS, certain accounts of vacated tenants have been determined to be uncollectible by management, and; WHEREAS, a majority of these tenants accounts have been, or will be turned over to a collection agency for continuing collection efforts; NOW, THEREFORE, BE IT RESOLVED by the Board of Commissioners of the Housing Authority of the County of Contra Costa that the following amounts be written off for collection loss for the quarter ending June 30, 1983: Conventional Program Dwelling Rent $29913.48 Legal Charges 621.00 Maintenance & Other Surcharges 29194.49 $5,728.97 ADOPTED ON 7-26-83 by the following vote of the Commissioners: AYES: Commissioners Fander. , McPeak, Torlakson, Schroder .- NOES: None. ABSENT: Commissioner Power: . ABSTAIN: None . CC : Contra Costa County Housing Authority County Counsel County Administrator 245 r y HOUSING AUTHORITY or rNc COUNTY OF CONTRA COSTA 3133 ESTUOILLO STREET P.O. BOX 2396 (613) 229.5330 MARTINEZ.CALIFORNIA 91963 CERTIFICATE I , Perfecto Villarreal , the duly appointed, qualified and acting Secretary/Treasurer - Executive Director of the Housing Authority of the County of Contra Costa, do hereby certify that the attached extract from the Minutes of the Regular Session of the Board of Commissioners of said Authority, held on __ July 26 , 1983 is a true and correct copy of the original Minutes of said meeting on file and of record insofar as said original Minutes relate to the matters set forth in said attached extract. IN WITNESS WHEREOF, I have hereunto set my hand and the seal of said Authority this _26th day of July 1983 (SEAL) �-� � �erfe o Villarreal , Secretary 208-jt-82 246 k THE BOARD OF COMMISSIONERS, HOUSING AUTHORITY OF THE COUNTY OF CONTRA COSTA RESOLUTION NO. 3401 RESCINDING RESOLUTION 3106 WHICH ESTABLISHED GOALS FOR RACIAL BALANCE 0 WHEREAS, on August 28, 1974, the Board of Commissioners of the Housing Authority of the County of Contra Costa adopted Resolution No. 3106 which established goals to promote racially-balanced communities and avoid concentrated racial pockets; and, WHEREAS, having been notified by the Affirmative Action Office of the Department of Housing and Urban Development, San Francisco Regional Office, that this practice was no longer permissible: NOW, THEREFORE, BE IT RESOLVED that the Board of Commissioners of the Housing Authority of the County of Contra Costa hereby rescind Resolution No. 3106, Establishing Goals for Racial Balance, and declare it null and void. Adopted on July 26 , 1983 by the following vote of the Commissioners: AYES: Commissioners Fanden, McPeak , Torlakson, Schroder. NOES: None. ABSENT: commissioner Powers . ABSTAIN: None . CC : Contra Costa County Housing Authority County Counsel County Administrator 247 a HOUSING AUTHORITY or na COUNTY OF CONTRA COSTA 7137 ESTUOILLO STREET F.O. BOX 2396 (616) 226.6339 MARTINEZ,CALIFORNIA 94662 CERTIFICATE I , Perfecto Villarreal , the duly appointed, qualified and acting Secretary/Treasurer - Executive Director of the Housing Authority of the County of Contra Costa, do hereby certify that the attached extract from the Minutes of the Regular Session of the Board of Commissioners of said Authority, held on July 26 , 1983 is a true and correct copy of the original Minutes of said meeting on file and of record insofar as said original Minutes relate to the matters set forth in said attached extract. IN WITNESS WHEREOF, I have hereunto set my hand and the seal of said Authority this 26th_--_ day of July 1983 (SEAL) er� o Villarreal , Secretary 208-jt-82 248 THE BOARD OF COMMISSIONERS, HOUSING AUTHORITY OF THE COUNTY OF CONTRA COSTA A pted this Order on July 26 , 1983 by the following vote: ES: Commissioners Fanden, McPeak, Torlakson, Schroder . NOES: None . ABSENT: Comlaissioner Powers . ABSTAIN: None. SUBJECT: Approve Audit Report on Non-HUD Management Funds for the Fiscal Year ending March 31, 1983, as submitted by John Griffin Accountancy Corporation. The Board of Commissioners, having received and reviewed a report from the Executive Director of the Housing Authority of the County of Contra Costa and a copy of the audit report as submitted by the John Griffin Accountancy Corporation: IT IS BY THE BOARD ORDERED that the audit report on Non-HUD Management Funds for the fiscal year ending March 31 , 1983, as submitted by the John Griffin Accountancy Corporation , be APPROVED. I hereby certify that this Is a true and correct copy of ah action taken and entered on the minutes of the Board of Supervisor%on the date shown. ATTESTED: r 6 /V3 J.H. OLS ON, C34VWi7V CLEF29 and ex of9cio Cierk cr the Doard Deputy CC : Contra Costa County Housing Authority County Counsel County Administrator 249 HOUSING AUTHORITY Or THE COUNTY OF CONTRA COSTA 3132 ESTUDILLO STREET F.O. BOX 2706 (615) 226.5770 MARTINEZ. CALIFORNIA 96552 CERTIFICATE I , Perfecto Villarreal , the duly appointed, qualified and acting Secretary/Treasurer - Executive Director of the Housing Authority of the County of Contra Costa, do hereby certify that the attached extract from the Minutes of the Regular Session of the Board of Commissioners of said Authority, held on `July 26 , 1983 is a true and correct copy of the original Minutes of said meeting on file and of record insofar as said original Minutes relate to the matters set forth in said attached extract. IN WITNESS WHEREOF, I have hereunto set my hand and the seal of said Authority this 26th day of July 1983 +_ (SEAL) Perllarreal , Secretary 208-jt-82 a 250 THE BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Adopted this Order on July 26. 1983 by the following vote: AYES: Supervisors Fanden, McPeak, Torlakson, Schroder NOES: None ABSENT: Supervisor Powers ABSTAIN: None SUBJECT: Referral by Board Order, Dated May 10, 1983, Regarding Subdivision 3790 (Little Creek Court), San Ramon Area The Board having on May 10, 1983 referred to the Public Works Director for report a letter, dated April 29, 1983, from Michael W. Rupprecht of Thiessen, Gagen and McCoy, attorney of Dame' Construction Company, Inc. requesting clarification of actions taken by the board on February 28, 1972 and April 17, 1973 as they relate to Subdivision 3790 and specifically whether they refer to street improvements, or residential lot improvements; and The Board having received a July 8, 1983 memorandum from the Public Works Director advising that the Board Orders dated February 28, 1972 and April 17, 1973 regarding Subdivision 3790 (Little Creek Court) relate to the acceptance of public street and storm drainage improvements only; IT IS BY THE BOARD ORDERED that the receipt of the aforesaid report is hereby ACKNOWLEDGED. I hereby certify that this Is a true and correct copy of an action taken and entored or the minutes of the Board of Supem!sore on the date Chown. ATTESTED: JUL 2 6 1983 J.R. OLSSON, COUNTY CLERK and ex officio Clark of the Board By :2 Deputy Orig. Dept. : Public Works (LD) cc: County Administrator County Counsel Public Works Director Thiessen, Gagen & McCoy Attn. Michael W. Rupprecht P. 0. Box 218 Danville, CA 94526-0218 B0726.t7 251 y ° BOARD OF SUPERVISORS . n0k4 ; M. G. Wingett, County AdministratorContra Costa �rATE ; July 22, 1983 Co �� t LeJECT: Legislation: Elections ��� `•,' .r.•.0 I r I C REQUEST)S) CR RECCw41E1i­OAT 10N(S J & RACK[a#OIJJ,D AJD JUST I F I CAT}ON Authorize County Administrator and Assistant Registrar to seek legislation which will restore the local option of allowing candidates to include other materials, including pictures, in their candidates' statement. See attached letter from County Administrator. i' s 1 `., ONT INVCO ON ATTACI..ENT; VCS ,.X nCCOYUCNO.TION Or COUr1Tv A011IN1 §TnATOn r1CCowNr11O.T1011 Or nO.NI) cc.. . ITT1:1 ' iOrl Or UO.rl l'1 pq July.. .i..._.__. .. __.._ .Lr.Nny,:rl •! nrCllNUTlrnrfi �.1..r,0 _- .. E• or 5vn[nv1G[v1.r V1 16'111:IIv CrIfT lry T1Ur TI11 IL A 11UC /� i111AI11.IC%j!i IAII!:1:r/1 /1 fff � AH) 1:(v InCCT CohV Or n11 Ar, ) IfY1 TN.I:r/ A vC S'. _ Arm CI-1TCnCo 014 T$4r 1.11ra1T1:5 or Tin- 1"AnD A rjnc"T. _ AIISTA IN: CK .'.111'I:rev 1 _!b1$ 011 760: DATE 1!'1 Qw11 J «.vkv 1. C01.1IITY CLC111< CC : County Administrator +� cx or r I C I o r_L Cr11c n(' T11[ npAno ' Elections is 252 �.a Board of Supervisors ` County Administrator Contra Tom Powers 1st District County Administration BuildingNancy C.Fanden Costa Martinez, California 94553 CC.. o 2nd District (415) 372-4080 County o Infi/ v 1..1 L�/ Robert 1.Schroder M. G.Wingett 3rd District County Administrator .Surma Wright McPeak 4th District Tom Torlakson 51h District July 18, 1983 RECEIVED Board of Supervisors Administration Building J. R. OtsSON 651 Pine Street aE dMOARD OF PEERRVISORS Martinez, California 94553 1290 B ... -.jr`:�:'� ur. Dear Board Members : On November 16, 1982, your Board ordered that legislation be included i.n the County's legislative program which would allow counties the option of including photographs in candidates' statements. This position was taken in response to AB .2678 (Chapter 428, Statutes of 1982) which prohibits the inclusion of "other materials" in the candidates' state- ments. Assemblyman Dominic Cortese is carrying AB 497 which makes other unrelated changes to Elections Code Section 10012, the section in question. I wrote to Assemblyman Cortese on May 23, 1983 asking him to accept an amendment to AB 497 to accomplish your Board' s direction in this matter. Assemblyman Cortese responded by letter dated June 29, 1983 indicating that he would not accept the suggested amendment. A copy of my letter and his reply are .attached. Also attached is a memo from Lon Underwood, Assistant County Registrar, dated July 13, 1983, providing further explanation for Assemblyman Cortese's unwillingness to pursue the amendment. In view of Los Angeles County's resistance to this provision, any amendment will probably have to -continue to exempt Los Angeles County from the option of including "other materials". I am, therefore, recommending that I be authorized to work with Mr. Underwood and through him the County Clerks' Association, as well as with the County Supervisors Association of California, to draft an amendment to Elections Code Section 10012 which will restore the option of including a candidate's picture and other material in the candidate's statement, at least in Contra Costa County. If your Board still wishes this flexibility, please approve .my recommendation. Respectfully, k1V M. G. WINGETT County Administrator MGW:clg cc: Lon Underwood Enclosures (3) t ° BOARI) OF SUPERVISORS M. G. Wingett, County Administrator Contra .ATE Cw y a : July 18, 1983 �J`'^ 1JBJECT; Legislation--Assembly Bill 1138 (Wyman) `� -" "r .v ECIFIC REOUESTIS ) CR RECCt-MEWATION(S ) & EiACKC:COUND AM, JU.STIFICATICW RECOMMENDATION: Decline to take a position on AB 1138. BACKGROUND/JUSTIFICATION: On May 17, 1983, the Board referred to our office a .Tetter from the Chairman, Adult Day Health Care Planning Committee, and President, Advisory Council on Aging, urging the Board to oppose AB 1138. AB 1138 would require the State Department of Health Services to administer a pilot project for adult day health care services to Medi-Cal recipients in private for profit facilities. The department would be required to submit reports to the Legislature on the progress of the pilot project. The bill provides that selection of pilot project facilities and preparation of the required reports shall be performed in consultation with representatives of both for- profit and nonprofit adult day health care facilities, as well as consumer representa- tives. The bill provides that the pilot program shall be funded to the extent possible for the 1982-1983 and 1983-1984 fiscal years, and program funding shall not adversely affect funding of nonprofit adult day health programs in place prior to enactment of this program. The bill specifies that its provisions shall only be operative upon the obtaining of any necessary waivers from the federal government, and the Director of Health Services is required to seek these waivers. The bill specifies that the pilot project would terminate January 1 , 1986. The Adult Day Health Care Planning Committee and the Council on Aging expressed concerns that the pilot programs would not be regulated, and that there was no provision for community involvement. They also expressed concern about having the nursing home industry expand into the field of Adult Day Pealth Care, but give no reasons for their concern. ONTINUCO ON ATTACJHENT: X VCS SIGNATUFC; X RECOMMENDATION OF COUPITV AOMINISTRATOn _ RECOM-ENDATION OF nOAND CCM ITTC1. ._X AI'PROVC OT" R 1r,'JAT1II?rI S .: . ION Or 110.111. Un _1�. . _ Arl•IJOV L'R A S IICCDMMCNRCR 7rC OF Sur[rrv15[vJ,. / X1 1(:RCOY CCNTIrY THAT TIJIS IS A TJJUC V Nw1J1 AI OIJS Iwll S 1:NT //� APID C.CVIRCCT CCT'Y Or AN ACTICVJ TAI<UtJ ArJD CrJTCRCD OJJ T14C MIrIJTCS Or Tln: DOARD AIISCNT' _ 4 AIISTAIN: -.._ or C.IR'CRVIS tS ON TIM: OATC SJOwrJ .cc: County Administrator �9�3 Advisory Council on Aging Chairman ATTr':T(:r) a�� Adult Day Health Care Planning Committee Chairman J oL ''C�' COCJVJTY CLCIJK Welfare Director Arlo rx orrlclo CLERKx r ' TI-JC nownD oY DCrtJrY r ` 253 , • -2- Recent amendments incorporated into the bill after the Council 's letter provide for unannounced on-site visits to the pilot programs and require that consumers be involved in selecting the pilot facilities and in designing and preparing the reports to the Legislature. With these amendments, AB 1138 passed the Assembly on June 16 on a vote of 72:0. In view of the recent amendments, the fact that the bill calls for only a limited pilot project with clear supervision by the State and semi-annual reports to the Legislature, and that the pilot project terminates after two years, there seems little to recommend that the Board oppose the bill. CSAC has taken no position on AB 1138. L 254 BOARD OF SUPERVISORS Ra+ : M. G. Wingett, County Administrator ltrd Costa 'ATE : July 22, 1983 co "J 11OJCCT: Child Abuse Funds--Assembly Bill 2994 • pCCIrIC REQUESTIS OR RCCCI- CWOATIOK(SJ At BACKGROUND AtO JU5TIr3CATi.Or9 RECOMMENDATION: Designate the Social Service Department as the department responsible for administering the request for proposal process and the ongoing contract monitoring and administration Of:,funds made available from the increased fee charged for certified copies of birth certificates pursuant to AB 2994 (Chapter 1399, Statutes of 1982). BACKGROUND/JUSTIFICATION: On December 14, 1982, the Board authorized the Auditor-Controller to establish a County Children's Trust Fund pursuant to Welfare and Institutions Code Section 18966 to receive deposits of funds resulting from the increase in fees for certified copies of birth certificates. For the period January 1--May 31 , 1983, this fund has accumulated $21 ,466, or about $4,000 per month. The Social Service Department would now like to move ahead with an RFP process for the awarding of contracts for programs pursuant to AB 2994. It is estimated that by June 30, 1984, there will be approximately $70,000. In order to undertake this process, the Board should designate the Social Service Department for this purpose. s ONTINUCO ON ATTAC1"CNT-. VCS SIONATURC: /�`%e� / ( • Cll/t—`SIL 1/�/IE'+�'• — i` _ _ rICC O��CNDAT ION Or COUr(TV AOYINI {TnATOn nCCONNr.NOATION O• IrOAIM ccw" ITT(:f xcoAn�nOVC •�- OTNC J7 /A aw • 1(r rr Or IIOArr 1'r Uu•.J_.-. .•-... . .. ...-..- AI•rr N('IVI:n A! IIr'CnNNr Nnr'() r.I..r.1. _. .. '•(C or SUnCrrV 1 Sd'v(_. '. 1 II;NI:IIV CcNTIrV THAT TI/1 (1 IS A JI(ur UrIAI/IuCYJr I All: l:rli Ar(.) (:Cvrn L'CT COrY Or Ath Ar, T I[Y( TA0(1:/( AVCS'. rIOCSt.. AT(n rNT L'nrD d+ TIt e(IruTC!'. or rIa' IInAn0 A U+r N7; _ wl)$TA IN: _ Ur .'.I n•,:nv l;fY)5 TIe: r)ATr t:Ir)r(( cc: County Administratorp3 County Auditor "TTton / G _ County Welfare Director ca.IrITT,""'" County Clerk Arm cx Orr' IC 10 CLCrr)( r)(' Tllr 1)oAnD Child Abuse Prev. Council �� .Drry ry s V 255 THE BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Adopted this Order on July 26, 1983 , by the following vote: AYES: Supervisors Fanden, McPeak, Torlakson, Schroder NOES: None ABSENT: Supervisor Powers ABSTAIN: None SUBJECT: Designation of the County as a Service Delivery Area for Job Training Services The Board having received a letter dated July 12, 1983, from K. R. Kiddoo, Director, State Employment Development Department, 800 Capitol Mall, Sacramento, CA 95814, advising that based on the recommendations of the State Job Training Coordinating Council, Governor Deukmejian has approved the County' s application for designation as a Service Delivery Area for job training ser- vices under the Job Training Partnership and Family Economic Security Acts ; and Mr. Kiddoo having further advised that a list of the Governor' s proposed SDA designations is being published to permit individuals and organizations affected by the designations to com- ment thereon and to provide cities and counties the opportunity to request revision of the proposed designations, and that any such requests must be postmarked no later than July 21, 1983, to be considered before final SDA designations are announced; IT IS BY THE BOARD ORDERED that the aforesaid communica- tion is REFERRED to the County Administrator and the Director of Manpower Programs . 1 hereby certify that this Is a true and correct copy of an action taken and entered on the minutes of the Board of Supervisors n the date shown. ATTESTED: 093 J.R. OLSSO ; (: iJN i Y CLERK and ex officio Clerk of the Board By � Deputy Orig. Dept.: :Clerk of the Board cc: County Administrator Manpower Programs Director L. 256 a � THE BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Adopted this Order on July 26, 1983 , by the following vote: AYES: Supervisors Fanden, McPeak, Torlakson, Schroder NOES: None ABSENT: Supervisor Powers ABSTAIN: None SUBJECT: Enterprise Zones The Board having received a letter dated July 13, 1983, from Ron Teninty, Business Representative, General Truck Drivers, Warehousemen and Helpers, Local No. 315, P. 0. Box 3010, Martinez, CA 94553, transmitting information (which also reflects said Local' s position) on the subject of Enterprise Zones and requesting the Board' s comments with respect thereto; IT IS BY THE BOARD ORDERED that said information is REFERRED to the County Administrator. 1 hereby certify that this Is a true and correct copy of an action taken and entered on iae minutes of the Board of Supervisors on the date shown. ATTESTED: , 9�'3 J.R. OLSSON, COUNTY CLERK and ex officio Clerk of the Board By �� Deputy Orig. Dept.: Clerk of the Board cc: Teamsters Local 315 County Administrator 257 THE BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Adopted this Order on July 26, 1983 , by the following vote: AYES: Supervisors Fanden, McPeak, Torlakson, Schroder . NOES: None ABSENT: Supervisor Powers ABSTAIN: None . SUBJECT: Child Abuse Prevention Services The Board having received a letter dated July 6, 1983, from Sheryl Walker, Project Director, Multicultural Coordinating Council for Children and Families Inc . , 390 Euclid, Oakland, CA 94610, advising that said Council has received a contract from the State Office of Child Abuse Prevention to offer technical assistance and training to organizations receiving funds from the State and counties to provide child abuse prevention and interven- tion services, focused primarily toward minority populations, and requesting certain information regarding organizations within the county that would qualify for such services under the county' s plan for distribution of AB 1733 and AB 2994 funds; and IT IS BY THE BOARD ORDERED that the aforesaid communica- tion is REFERRED to the County Welfare Director. 1 hereby certify that this Is a true and correct copy of an action taken and entered on the minutes of the Board of Supervise on the date shown. ATTESTED: y 4j J.R. OLSSON, COUNTY CLERK and ex otticio Clerk of the Board By Deputy Orig. Dept.: Clerk of the Board CC: Multicultural Coordinating Council County Welfare Director County Administrator 258 THE BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Adopted this Order on July 26, 1983 , by the following vote: AYES: Supervisors Fanden, McPeak, Torlakson, Schroder NOES: None ABSENT: Supervisor Powers ABSTAIN: None SUBJECT: Provision of Medical Care in Contra Costa County The Board having received a letter dated July 11, 1983, from Joseph Ross, M.D. , President, Alameda-Contra Costa Medical Association, P. 0. Box 2895, Oakland, CA 94618, requesting informa- tion and clarification of the Board' s present policy concerning the potential use of private medical facilities in the County as an alternative to the construction of a new county hospital; IT IS BY THE BOARD ORDERED that, consistent with the recommendation of the Finance Committee in its report on the 1983-84 County Budget, this matter is REFERRED to the Joint Con- ference Committee . 1 hereby certify that this Is a true and correct copy of an action taken and entered on the minutes of the Board of Supervisors an the date shown. ATTESTED: '?`I / 83 J.R. OL SWZ OUNTY CLERK and ex officio Clerk of the Board By Deputy Orig. Dept.: Clerk of the Board cc: Alameda-Contra Costa Medical Assn. Health Services Director County Administrator Joint Conference Committee 259 4 At 9 : 50 a.m. the Board recessed to meet in Closed Session in Room 105 , the James P . Kenny Conference Room, County Administration Building, Martinez , CA to discuss potential litigation and obtain legal advice from County Counsel . The Board reconvened in its Chambers at 10 : 20 a.m. and proceeded with the agendaed items . 260 l ° BOARD OF SUPERVISORS ""' Finance Committee Ccntra 'ATE July 26, 1983 �l.J.7ld Ls.IECT: Control of Water Hyacinths in the Delta c`"�y "tr PECIFIC REOUEST)S) CR RCC044DMATION(S) & MCKGR0UIm Ala JU.STIrICATICN RECOMMENDATIONS: 1 . Direct the Public Works Department to request a report from the Contra Costa Water District regarding the methodology used in monitoring the 2,4-D spraying in San Joaquin County and the results of their tests on the intake at Rock Slough. 2. Direct the Agricultural Commissioner to obtain a letter from the State Department of Food and Agriculture on the legality of using Rodeo for the control of water hyacinths.. in the Delta in response to a question raised that Rodeo should,not be used in a tidal zone. 3. Direct the Public Works Department to discuss with the State Water Resources Control Board the possibility of using the $10,000 made available through the intervention of Assemblyman Robert Campbell for a demonstration program designed to mechanically harvest water hyacinths in the Rock Slough area, with the under- standing that Contra Costa County would provide an equivalent match of $10,000. 4. Appoint Mr. David Okita, Public Works Department, as the County contact person to coordinate the water hyacinth control program with the State Water Resources Control Board and direct the County Administrator to so advise Assemblyman Campbell . 5. Refer this matter to the Water Committee, with a request that Public Works and the Agricultural Commissioner report to the Water Committee on August 1 , 1983, and remove this matter as a referral to the Finance Committee. BACKGROUND/JUSTIFICATION: On July 25, 1983, the Finance Committee met with representatives from the Public Works Department, the Health Services Department, and the Agricultural Commissioner to review Assemblyman Campbell ' s letter of July 7, 1983 advising the County that he had arranged for $10,000 in State funds to be made available as an alternative to spraying in order to control the water hyacinths yin the Delta. We received a report from Dave Okita, Environmental Control Division, Public Works Department, identifying three options for a demonstration program utilizing the State funds and County funds. � TINVED ON ♦TTwC,N CNT; VCS SIGNATUAC: nCCO__CND•TION Or COUNTY AOYINISTnATOn � TNCn n cco•,.IrNn.T ION o. oo."r) C(-•..17 TO I . •r•noovc _ l��nSov� �,.Iw rLn7Els ,. Tom Torlakson Sunne W. McPeak : . 10., O.. I,q.•,n ur. J.u].Y.._.� ..19_.3. . _ ... ..w•uOv1[n •, nr'C(+..Nrr.n Cr� ,r 17 In addition to approving the aforesaid recommendations , the Board also requested that a letter be sent to Assemblyman Campbell thanking him for his efforts in securing the funding and advising him of what the program will include . 1,c or I 1 041:II1:11Y CCnTlry TIVIr T111lu w n1. l IINeNI•rC�JS Iw116 i;II7 UC w YC -• A,O r;(V II7I;CT CC Or f. n1/ A7 IQII 7Aul'rl S' ,CCS: ATI!,C NT: - Arin rNTcnco CY4 T1� F,IIIITI:s or Tl rl; IY�4Np AIISTAINI Gr :'.1 II.1:rIV l:L71S C11J TIT: r)A71: !;I C)W[-I cc: County Administrator ATrCnTcn July 26, 19$3,_. Agricultural Commissioner J.11. CK-c:,oN. CO.II,TY CLCI11 - — Public Works Director Ar f7 Ex Orriclo CI.EIIK r,r Tb/C nOAno Environmental Control Div.--Public Works r' County Auditor aT �e _,( c� 0•_ �L6 •p oEr1JTT Jeanne 0, i441io 2001 -2- Mr. deFremery outlined the spraying which has occurred in San Joaquin County and the monitoring which has occurred primarily by the Contra Costa .Water District to ensure that no unsafe levels of 2,4-D intruded into their intake at Rock Slough: Data indicate that the detected levels of 2,4-D were well within any identified safety levels and were, in fact, below levels that had been anticipated. Because of the pending court action, spraying of 2,4-D is not feasible this year. Therefore, mechanical harvesting appears to be the only viable alternative for the current year. Estimates are that mechanical harvesting would cost between $3,000 and $4,000 per mile. Total mechanical removal would thus run approximately $500,000. The State has made available $10,000 in Clean Water Act funds which must be used for a demonstration or research project. Mr. deFremery noted that no biological control has been implemented in Contra Costa County. Our Committee. believes that protection. of the Rock Slough area should be our primary focus for mechanical removal . Rather than having a project conducted with County staff, we would prefer to explore the possibility of supplying our matching funds to the State and have the. State conduct a demonstration program involving the mechanical removal of water hyacinths in the Rock Slough area. We believe this can be accomplished for close to the $20,000 which is available. We believe that the above-noted recommendations are, therefore, appropriate and would like these items responded to at the Water Committee meeting next week. 262 TO: BOARD OF SUPERVISORS . FROM: Finance Committee `M ItI a nC�oysta � DATE: V`i�'"taJuly 25 , 1983 1`7 SUBJECT: Allocation from the Special District Augmentation Fund. SPECIFIC REQUEST(S) OR RECO14MENDATION(S( & BACKGROUND AND JUSTIFICATION RECOMMENDATION: Allocate $1, 760 from the Special District Augmentation Fund to the Danville Parking Maintenance District. BACKGROUND: A revenue estimate of $5, 000 from the sale of an easement which was included in the District' s budget did not materialize. As a result of this revenue shortage, the fund has a deficit balance of $1, 760 . The City of Danville assumed responsibility for district property, effective July 1, 1983, and the district no longer exists . An allocation of $1, 760 from the Special District Augmentation Fund which will clear the deficit fund balance is recommended. CONTINUED ON ATTAC►M ENT: YES SIGNATURE: RECOMMENDATION OF COUNTY ADMINISTRATOR -xXRECOMME DATION OF BOARD COMMITTEE li;IE APPROVE K &TZZ -- ` SIGNATURE s : Supervisor T. /Torlakson Supervisor :S. W. McPeak ACTION OF BOARD ON ` APPROVED AS RECOMMENDED OTHER VOTE OF SUPERVISORS �-7''''' 1 HEREBY CERTIFY THAT THIS IS A TRUE UNANIMOUS (ABSENTzL AND CORRECT COPY OF AN ACTION TAKEN AYES: HOES. AND ENTERED ON THE MINUTES OF THE BOARD ABSENT: ABSTAIN: OF SUPERVISORS ON THE DATE SHOWN. M. Auditor-Controller ATTESTED Public Works County Service R. ssay. COUNTY CLERK Area Coordinator County Administrator AND EX OFFICIO CLERK OF THE BOARD 3 DEPUTY TO. BOARD OF SUPERVISORS FROM: Finance Committee Cw, tr,a CWLQ DATE: July 25, 1983 ro11 t SUBJECT: Management Report of Peat, Marwick, Mitchell & Co. v Providing Comments and Recommendations for Improvement of Internal Control or Operating Efficiencies. SPECIFIC REQUEST(S) OR RECOMMENDATION(S) a BACKGROUND AND JUSTIFICATION RECOMMENDATION: Accept written responses furnished by county departments to comments and recommendations included in the subject report. BACKGROUND: Peat, Marwick, Mitchell & Co. , Certified Public Accountants, submitted a report dated November 26 , 1982 to this Board of Supervisors which provided comments and recommendations on certain conditions and matters identified in the examination of financial statements for fiscal year 1981-1982 . The report repeated recommendations included in the interim examination and reported in the letter dated October 28, 1982 . This matter was referred to the Finance Committee by the Board on March 1, 1983 . The recommendations and comments were studied by the departments involved. Written responses to these matters were received from the departments . Departments indicated concurrence and general agreement with most recommenda- tions . Actions have been taken or are under various stages of implementation with respect to many of these recommendations . Some items remain under study as the fiscal requirements for implementation are not available. The comments and departmental responses were reviewed by the Grand Jury Audit Committee, Peat, Marwick, Mitchell & Co. staff and the Finance Committee and determined by all to be acceptable. The Finance Committee recommends acceptance of the responses and removal of this item as a committee referral. CONTINUED ON ATTACHMENT: YES SIGNATURE: RECOMMENDATION OF COUNTY ADMINISTRATOR XX RECOMMENDATION OF BOARD COMMITTEE X APPROVE / / 71'_W�/ / SIGNATUREISI: Supervisor/Jl/T. Tor�la/k�.son Supervisor S. W. McPeak ACTION OF BOARD ON July 26, 1983 APPROVED AS RECOMMENDED OTHER VOTE OF SUPERVISORS t HEREBY CERTIFY THAT THIS IS A TRUE UNANIMOUS (ABSENT AND CORRECT COPY OF AN ACTION TAKEN AYES• NOES: AND ENTERED ON THE MINUTES OF THE BOARD ABSENT: ABSTAIN: OF SUPERVISORS ON THE DATE SHOWN. cc: ATTESTED , J.RC,6Lsso4, COUNTY CLERK AND Ex OFF 1 C 1 O CLERK OF THE BOARD 2641 (9y1- YS BY .DEPUTY 1 DO.IRD OF SUPERVISORS rol ; Finance Committee Contra ltra CW 1C.1 ,TE '. July 25, 1983 Cryl/ ,aJECT; State and County Budgets �"' �`7 'ECIFIC REOUEST( S ( CR RECOMMCt DATIONS ( & BACKGROUND AND JUSTIFICATION RECOMMENDATIONS: (1) Refer to the County Counsel and County Administrator issues of unfunded mandates recently imposed by the State and request an analysis of options available to the Board including refusal to implement the statutes . (2) The County Administrator is requested to review and recommend whether layoffs should occur in programs unlikely to be funded under various anticipated changes in the State budget and to prepare a list of County programs that would have to be cut based on the County funding level included in the current State budget. BACKGROUND: The Finance Committee at its meeting of July 25 reviewed with the County Administrator, County Counsel and other interested parties the magnitude of the budget cuts that would be necessary if the current State budget is not modified. During the discussion committee members requested that the County Administrator review various budget options and determine whether it is desirable to initiate layoff procedures for programs unlikely to be continued with the funds available. The County Administrator was also requested to develop a listing of County programs to be eliminated or reduced to bring the County budget into conformance with revenues available in the State budget at its current level. The committee requested a review of SB 14 (1982) which provides mandates for child protective services , the mandate created by the Governor calling a special election in December, 1983, and County administrative costs of the accelerated property tax provisions of SB 813. Additionally, the County Administrator and County Counsel were regtfested to develop lists of all recent unfunded mandates and to develop options for the County which may include refusal to implement those provisions requiring additional County resources . 1 ]NTINUED ON ATTACr"ENT: YES SIGNATURE; __ RCCOMMCNOAT ION Or COUNTY AOMINISTRATOR RECOMMENDATION Or BOARD CO"MITTCC X ♦r•n u O V C O T H r i Su ervisor T. Tor akson Supervisor S. W. McPeak IrNATU1lE 15 1'. P '1 C P : t10'� Or I\n AICD DII July 26.E1�8� Ar�M 110VCD AS RCC OMMCND L'D OTNCR )TL- or SUPERVISCO S I 1-CRCtrY CERTICY THAT THIS IS A TRUC xur+nrlIMCTJS ( nI15Cr7T _. .--.-_ AND CORRECT COPY Or AN ACTION TAKEN AVC S' N>CS'• AND CNTERED ON TIC MINUTES OF THIS DOARD Or SUPERVISORS ON T/1C DATC SHOWN. ATTCSTCD ,,/ .�/ o If X,3 cc : County Counsel J .R. SSON. COUNTY CLERK County Administrator AND Ex OFFICIO CLERK OF THQ DOARO Personnel Director DY .DEPUTY 265 THE BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Adopted this Order on July 26, 1983 , by the following vote: . AYES: Supervisors Fanden, McPeak, Torlakson, Schroder NOES: None ABSENT: Supervisor Powers ABSTAIN: None , SUBJECT' -Purchase of Property at 550 School Street, Pittsburg As requested by its Finance Committee, the Board on July 19, 1983 having continued to this date and time consideration of the proposal to consumate purchase of property located at 550 School Street, Pittsburg, California from the Los Medanos Community Hospital District; and The Board having this day again considered this matter; and Good cause -appearing therefor, IT IS BY THE BOARD ORDERED that the aforesaid matter is continued to August 2, 1983 at 10:30 a.m. I hareby corMy that this is a true and correct COPY ot en aciron tsksn and entered on the minutes of the Board of S11a3rvi rs on the date shown. ATT ESTE' J.R. C.L!3.30N, CODUTY CLERK .and ox officio Clerk of the Board By , DeputY Orig. Dept.: Clerk of the Board Cc: 266 J/krc � i THE BOARD OF SUPERVISORS CONTRA COSTA COUNTYe CALIFORNIA Adopted this Resolution on July 26, 1983, by the following vote: AYES: Supervisors Fanden, McPeak, Torlakson and Schroder NOES: None ABSENT: Supervisor Powers RESOLUTION 83/ 914 (Government Code Sec. 25350) SUBJECT: Consummate Purchase and Accept Avigation Easement for Buchanan Field Airport Runway 19-R F.A.A. Proj. No.6-06-0050-03 County No. 0841-4016-6X5320 Concord Area The Board of Supervisors of Contra Costa County RESOLVES THAT: This Board on June 14, 1983 passed Resolution of Intention No. 83/845 and Notice fixing July 26, 1983 at 10:30 A.M. in its Chambers, County Administration Building, Martinez, California, as the time and place where it would meet to consuTmate the purchase of the real property described therein from Carole A. Krasko, said property being required for airport purposes. Said Resolution was duly published in the Contra Costa Times in compliance with Govt. Code Section 6063. The Board hereby consummates said purchase and approves the Purchase Agreement dated June 1, 1983, between Carole A. Krasko and the County for an avigation easement for Runway 19R at Buchanan Field Airport, Concord, California, and authorizes the Public Works Director to sign the Purchase Agreement on behalf of the County. The County Auditor-Controller is hereby DIRECTED to draw a warrant in favor of Western Title Insurance Company, Escrow No. D-314501-9, for $5,649.00 for said property for payment to Carole A. Krasko, upon her conveying to the County an easement therefor. Said avigation easement, dated June 1, 1983 is hereby ACCEPTED and the Real Property Division is ORDERED to have it recorded, together with a certified copy of this resolution. 1 heretsy certify that this Is a dve and correct espy of an action taken and entered on the nwrli.,tMs a!the Board of Supervisors on the date show.. ATTESYED: C93 J.R. OLSS , t' PITY G�_. ?•: and ex officlo Clerk of the Board Deputy Orig. Dept.:Public Works (RP) cc: Auditor-Controller (via R/P) Public Works Accounting County Recorder (via R/P) Buchanan Field Airport RESOLUTION 83/914 B00726.t6 267 .. i RESOLUTION NO. 9a RESOLUTION OVERRULING PROTESTS Assessment District No. 1981-1 , San Ramon Valley Boulevard The Board of Supervisors of the County of Contra Costa resolves: On June 28 , 1983, the Board of Supervisors opened a public hearing on the resolution of intention and the engineer' s report on the proposed improvement in Assessment District No . 1981-1 , San Ramon Valley Boulevard , Contra Costa County, California. At or before the time set for hearing, certain interested persons made protests or objections to • the proposed improvement , the extent of the assessment district or the proposed assessment. The Board closed said hearing and continued consideration of all matters to the 26th day of July, 1983. The Board hereby overrules each of these protests, written or oral . The Board finds that the protest against the proposed improvement ( including all written protests not withdrawn in writing before the conclusion of the protest hearing) is made by the owners of less than one-half of the area of the land to be assessed for the improvement. RESOLUTION NO. Y319a9 2 6u s , r I HEREBY CERTIFY that the foregoing resolution was duly and regularly adopted by the Board of Supervisors of the County of Contra Costa, State of California, at a regular meeting thereof, held on the 26th day of July, 1983. ATTEST: JAMES R. OLSSON, Clerk Byo — Deputy Clerk RESC)LL'71f??,; �y�n S.�f9�-q 269 c.�3 i RESOLUTION NO. 83 9�0 RESOLUTION APPROVING REPORT AND ASSESSMENT AND ORDERING IMPROVEMENT Assessment District No. 1981-1, San Ramon Valley Boulevard The Board of Supervisors of the County of Contra Costa resolves: This Board has taken a series of actions preliminary to ordering the improvement in Assessment District No. 1981-1, San Ramon Valley Boulevard, Contra Costa County, California, and now makes the following findings and orders: 1. The Board adopted a map showing the boundaries of the land benefited by the proposed improvement. A copy of the boundary map was filed in the office of the County Recorder of the County of Contra Costa in the Book of Maps of Assessment Districts. 2. The Board adopted its Resolution of Intention to order the improvement described therein under the Municipal Improvement Act of 1913, and directed MICHAEL J. MAJORS, CIVIL ENGINEERS, INC. , as the Engineer of Work for the assessment district, to prepare the report required by Section 10204 of the Streets and Highways Code. The improvement is generally described as follows: 1. The construction or acquisition of street, storm drainage and utility improvements in San Ramon Valley Boulevard from Old Crow Canyon Road to a point 1000 feet north of Greenbrook . Drive; in Omega Road from Purdue Road to approximately 350 feet north of Purdue Road; in Purdue Road between Omega .Road and_San .Ramon Valley Boulevard and in a proposed storm drainage easement located 300 feet northerly of and parallel to Purdue Road; said easement running between Omega Road and San Ramon Valley Boulevard. The improvements shall consist of the following: Clearing, grading, curbs and gutters, sidewalks, 270 COPY street monuments, street lights, street name signs, traffic signs, striping, sanitary sewers and ap- purtenances, storm drainage facilities, water distribution facilities, fire hydrants and appurtenances, landscaping, utility conduit street crossings, and the relocation of existing utility facilities, together with the acquisition of all necessary interests in real estate. 2. The installation of sanitary sewers and appurtenances to serve the petitioning parcels of land in the Alamo Oaks Subdivision, •together with the acquisition of any necessary interests in real property. 3. The Engineer of Work filed the report as directed, and the Board of Supervisors called a hearing on the report as required by Section 10301 of the Streets and Highways Code. Notice of the hearing was given by publication, by street posting and by mailing to .affected property owners, all according to the Municipal Improvement Act of 1913. Affidavits of publication, posting and mailing were filed with the County Clerk. 4 . At the time and place for which notice was given, the Board of Supervisors conducted a public hearing and gave every interested person an opportunity to object to the proposed improvement, the extent of the assessment district, or the proposed assessment. Following the hearing, consideration of all matters was continued to the 12th day of July, 1983 , and was further continued to the 26th day of July, 1983. 5. The Engineer of Work was directed to file an amended report. 6. The Board finds that written protests against the proposed improvement have not been made by owners representing more than one-half of the area of the land to be assessed for the improvement. 7. The documents and events described in paragraphs 1 to 4, inclusive, are .stated here in tabular form, with their 2 RESOLUTION NO. 8.91930 271 F dates and, where appropriate, their numbers. All documents are now on file with the County Clerk. Document •or Event . Date Number . a. Resolution approving Boundary Map 5/17/83 83/768 b. Boundary Map filed with County Recorder 5/24/83 - c. Resolution of Intention 5/17/83 83/770 d. Filing of Engineer' s Report 5/17/83 - e. Resolution accepting Report 5/17/83 83/771 f. Certificate of Mailing Notice of Improvement 5/25/83 - g. Affidavit of Publication of Notice of Improvement 5/25/83 - h. Certificate of Posting of Notice of Improvement 6/6/83 - i. Public hearing conducted 6/28/83 - j. Filing of Amended Engineer' s Report 7/26/83 - 8. The Board approves the Amended Engineer' s Report and each component part of it, including each exhibit incorporated by reference in the report. 9. The Board finds that the Engineer of Work, in the Amended Engineer ' s Report has fairly and properly apportioned the cost of the improvement to each parcel of land in the assessment district in proportion to the estimated benefits to be received by each parcel, respectively, from the improvement. The Board of Supervisors hereby confirms and levies each individual assessment as stated in the Amended Engineer' s Report. 10 . This Board of Supervisors orders the improvement described in paragraph 2 and as detailed in the Amended Engineer ' s Report. , 11. Serial bonds representing unpaid assessments, and bearing interest at a rate not to exceed twelve percent.-(12%) . per annum, will be issued in the manner provided by the Improvement Bond Act of 1915 (Division 10, Streets and Highways Code) , and the last installment of the bonds shall mature fourteen years from the second day of July next succeeding ten RESOLUTION N0, 8319-30 3 272. C C (10) months from their date. 12. According to Section 10603 of the Streets and Highways .Code, the Board designates the County.Treasurer to collect and receive payment of the assessments. I HEREBY CERTIFY that the foregoing resolution was duly and regularly adopted by the Board of Supervisors of the County of Contra Costa, State of California, at a regular meeting thereof, held on the 26th day of July, 1983. ATTEST: JAMES R. OLSSON, Clerk By aha Deputy Clerk R''SOLUTION NO. s,315 Jd 4 273 PF G 3 RESOLUTION NO. 83/931 RESOLUTION AUTHORIZING CHANGE ORDERS I - l _ Assessment District No. 1981-1 , San Ramon Valley Boulevard The Board of Supervisors of the County of Contra Costa resolves: The Board of Supervisors hereby authorizes the Director of Public Works of Contra Costa County to issue change orders for the work in Assessment District No. 1981-1, San Ramon Valley Boulevard, Contra Costa County, California, under the following conditions: 1. To correct clerical and technical errors in the plans and specifications. 2. To modify the design of the improvement to accord with better engineering practice or to achieve economy of construction. 3 . To adjust the design of the improvement to utility locations, soil conditions, or other conditions unknown or uncertain when plans were drawn. Cost increases in change orders issued under this authority shall not aggregate more than the amount set aside for construction contingencies in the cost estimate approved by the Board of Supervisors. I HEREBY CERTIFY that the foregoing resolution was duly and regularly adopted by the Board of Supervisors of the County of Contra Costa, State of California, at a regular meeting thereof, held on the 26th day of July, 1983. ATTEST: JAMES R. OLSSON, Clerk Deputy Clerk RESOLUTION 83/931 274 G RESOLUTION NO. 83 RESOLUTION ESTABLISHING BOND RESERVE FUND Assessment District No. 1981-1, San Ramon Valley Boulevard The Board of Supervisors of the County of , Contra Costa resolves: 1. There is hereby created a special fund to be designated Special Reserve Fund, Assessment District No. 1981-1, San Ramon Valley Boulevard, Contra Costa County, California. 2. Out of the proceeds of the sale of improvement bonds to represent unpaid assessments in Assessment District No. 1981-1, San Ramon Valley Boulevard, there shall be deposited in the special reserve fund the amount designated for this purpose in the report required by Section 10204 of the Streets and Highways Code and approved by this Board of Supervisors, reduced by an amount which bears the same ratio to the amount set forth in the report as the amount of assessments paid in cash bears to the total amount of assessments. 3 . During the term of the improvement bonds, the money in the special reserve fund shall be available for transfer into the redemption fund for the bonds pursuant to Section 8808 of the Streets and Highways Code. The amount so advanced shall be reimbursed to the special reserve fund from the proceeds of redemption or sale of the parcel for which payment of delinquent assessment installments was made from the special reserve fund. 4 . If any assessment is prepaid prior to the final maturity of the bonds, the amount of principal which the assessee is required to prepay shall be reduced by an amount which is in the same ratio to the original amount of the special RESOLUTION NO, 33)?-5-3 �10 Py 275 l reserve fund, together with accrued interest, as the original amount of the prepaid assessment bears to the total amount of assessments originally levied in Assessment District No. 1981-1, San Ramon Valley Boulevard. The reduction in ,the amount of principal prepaid shall be compensated for by a transfer from the special reserve fund to the redemption fund for the bonds of a like amount. 5 . In order to prevent the reserve fund from exceeding the reserve limitations set by federal statute and regulation, the County Treasurer is hereby authorized and directed to make transfers of accrued interest from the reserve fund to the bond redemption fund from time to time, and to establish pro rata credits against annual installments of assessment principal and interest in a like amount in the year following the year of transfer. 6 . When the amount in the special reserve fund equals or exceeds the amount required to retire the remaining unmatured bonds (whether by advance retirement or otherwise) , the amount of the special reserve fund shall be transferred to the redemption fund for the bonds, and the remaining installments of principal and interest not yet due from assessed property owners shall be cancelled without payment. RESOLUTION NO. 931 93, 276 2 I HEREBY CERTIFY that the foregoing resolution was duly and regularly adopted by the Board of Supervisors of the County of Contra Costa, State of California, at a regular meeting thereof, held on the 26th day of July, 1983. ATTEST: JAMES R. OLSSON, Clerk By�/�'� Deputy Clerk RESOLUTION NO. 83/9302 3 2'7, c 3 C_ a_ RESOLUTION NO. 83/933 RESOLUTION CONCERNING FORECLOSURE OF DELINQUENT ASSESSMENT LIENS Assessment District No. 1981-11 San Ramon Valley Boulevard The Board of Supervisors of the County of Contra Costa resolves: 1. If any installment of the principal or interest of any assessment levied in Assessment District No. ' 1981-1, San Ramon Valley Boulevard, Contra Costa County, California, becomes delinquent, the Board of Supervisors shall cause the filing of an action in the Superior Court of the County of Contra Costa to foreclose the lien of the delinquent assessment pursuant to the authority given in Section 8830 and following of the Streets and Highways Code of the State of California. This action shall be filed not later than one hundred fifty (150) days following the date of delinquency. 2. This resolut.ion is adopted as an inducement to the purchase of improvement bonds to be issued in Assessment District No. 1981-1, San Ramon Valley Boulevard, Contra Costa County, California, and Paragraph 1 hereof shall constitute a covenant to the bondholders. I HEREBY CERTIFY that the foregoing resolution was duly and regularly adopted by the Board of Supervisors of the County of Contra Costa, State of California, at a regular meeting thereof, held on the 26th day of July, 1983. ATTEST: JAMES R. OLSSON, Clerk B R ZZ7J Deputy Clerk RESOKUTION NO. 83/933 278 r. RESOLUTION NO. 9,319S.41__ RESOLUTION AWARDING CONTRACTS Assessment District No. 1981-1, San Ramon Valley Boulevard The Board of Supervisors of the County of Contra Costa resolves: The County of Contra Costa has received public bids for the construction of improvements in Assessment District No. 1981-1, San Ramon Valley Boulevard, Contra Costa County, California. The Engineer of Work has reviewed the bids and now recommends award of the construction contracts to the lowest responsible bidders : Gallagher & Burk, Inc . , bid price $1, 198 , 965 . 55 , for San Ramon Valley Boulevard work; and to Overmiller, Inc . , dba Roto-Rooter Sewer Service, bid price $66 ,337 . 00 , for Oak Road and Smith Road. The Board of Supervisors therefore awards the contracts to those bidders . All other bids are rejected. The Board of Supervisors directs the County Clerk to publish a notice of award of contracts. The Board of Supervisors authorizes and directs the Chairman. of the Board and the County Clerk to sign written contracts for the construction when they are presented to them for signature, along with surety bonds and insurance certificates required by: the construction specifications . COPY R�5CLU1'l�rJ Tfta891s,� � . 279 I HEREBY CERTIFY that the foregoing resolution was duly and regularly adopted by the Board of Supervisors of the County of Contra Costa, State of California, at a regular meeting thereof, held on the 26th day of July, 1983. ATTEST: JAMES R. OLSSON, Clerk By •� RESOLUTION NO. $319356 200 P _ ._.. . THE BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Adopted this Order on July 26, 1983 , by the following vote: AYES: Supervisors Fanden, McPeak, Torlakson, Schroder NOES: None ABSENT: Supervisor Powers ABSTAIN: None SUBJECT: Hearing on Appeal of Richard Cobb This being the time for hearing on the appeal of Richard Cobb, from an Administrative Decision of the Appeals and Complaints Division of the Social Service Department; and Hearing having been opened and Mr. Cobb having responded to questions of the Board members reqarding his failure to keep a counseling appointment; and Audrey Sturgess, representing the Appeals and Complaints Division of the Social Service Department, having commented on the procedures required of recipients to maintain eligibility; and Supervisor Tom Torlakson having advised that he did not find any new information to disagree with the decision of the Social Service Depart- ment's Hearing Officer and therefore, having recommended that the appeal be denied; and There being no further discussion, IT IS BY THE BOARD ORDERED that the decision of the Appeals and Complaints Hearing Officer is upheld on the basis of the evidentiary hearing decision and that the appeal of Richard Cobb is denied. I hereby certify that this Is a true and correct copy of an action taken and entered on the minu:as o: the Board of SupervisJUL ron he date shown. ATTESTED: JJ 6 1983 J.R. OLSSON, COUNTY CLERK and ex officio Clerk of the Board By , Deputy Orig. Dept- Clerk of the Board CC: Social Service Department Dorothy Bohannon , County Counsel County Administrator Richard Cobb 281 THE BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Adopted this Order on July 26, 1983 by the followingvote: AYES: Supervisors Fanden, McPeak, Torlakson, Schroder NOES: None ABSENT: Supervisor Powers ABSTAIN: None SUBJECT: Public. Hearing on .the Future of County Hospital The Board on July 19, 1983 having fixed July 26, 1983 at 3 P.M. as the date and time for a public hearing at which time the Board will receive any oral or written 'testimony on the content of the County Administrator's letters of July 8 and July 18, 1983 on the future of the County Hospital ; and A. J. Berardino, M.D. , having testified on behalf of 45 physicians in the San Ramon Valley regarding the need for a full service hospital in the San Ramon Valley, and the fact that the County Hospital bed situation is complicating the situation and requesting that the Board of Supervisors agree to give up sufficient surplus licensed bed capacity so that a hospital can be built in the San Ramon Valley; and Karl Grossenbacher, representing the Gray Panthers of West Contra Costa County, having expressed his concern about the need for cost containment in health care; the need to reduce fee-for-service medical care, and the need to reduce profits in the health care field; and Jill Churchman, representing Social Services Union, Local #535, having read a statement to the Board regarding the need to maintain a county hospital ; and Andrew Young, Vice-Chairman of the San Ramon .Valley Committee on Hospital Proposals, having read a statement expressing his opinion that the . County' s excess beds are needed in the San Ramon Valley; and The Honorable Diane Schinnerer, Mayor of the City of San Ramon, having recommended that the County build a small hospital to meet special needs which cannot be met by other hospitals and contract with other hospitals for the majority of the health care needs of the indigents, and having recommended that the County put its surplus beds out for bid immediately; and The Honorable Lillian J. Pride, member of the Board of Trustees of Los Medanos Community Hospital District, and Efton Hall , Administrator, Los Medanos Community Hospital , having made a joint report suggesting that the Board review the report from the Committee on the Future of the County Hospital and having maintained that possibly contracting out of all inpatient services is not feasible, and that the recommendations of the Committee on the Future of the County Hospital that the County rebuild a county hospital in central County and contract for services in east and west County are still viable; and Donna Casey Gerber, representing the California Nurses Association, having expressed her agreement with the testimony provided by the representatives from the Los Medanos Community Hospital District that the County should maintain a County Hospital ; and Patricia Leigh Wilson, a citizen of San Ramon, having urged the Board to release their surplus beds for use elsewhere; and John Lee, M.D. , representing the Contra Costa County Hospital Medical Staff, having read a prepared statement regarding the need to maintain a County Hospital , either directly or indirectly; and 282 -2- Lee Domanico, Administrator, Delta Memorial Hospital , having indicated his hospital ' s willingness to do their share in serving indigents, having noted that Delta Memorial Hospital has cooperated in delaying their Certificate of Need application in order to further the "batching" process, and having expressed the hope that Delta Memorial Hospital does not jeopardize their Certificate of Need application by having agreed to these delays; and J. Kendall Anderson, Chief Executive Officer with John Muir Memorial Hospital , having read a prepared statement noting the substantial changes which are occuring in inpatient utilization and the provision of health care generally, and urging the County to do what is in the best interests of all patients; and Ron Teninty, representing Teamsters' Local#315, having referenced a letter from Teamsters Local #315 to the Board of Supervisors dated July 20, 1983, and urging that the County continue to meet its obligation to the citizens of the County by retaining the responsibility and direct control of the County Hospital ; and Henry Clarke, General Manager, Contra Costa Employees Local No. 1 , having urged the Board to continue efforts to obtain an exclusive Medi-Cal contract to actively market the Contra Costa Health Plan and to remodel or rebuild the county hospital ; and Ray Taylor, former County Supervisor; and Martinez resident, having noted that the County Hospital is a well-run facility which the Board should be proud of, and that full consideration should be given to keeping the county hospital in Martinez; and Written comments having been received from Mattie Adams and Olequrite Pruitt of Richmond that the County should continue .to operate a county hospital ; and George Degnan, M.D. , former Medical Director, Contra Costa County Hospital , having commented on the need for an emphasis on outpatient care, prevention, and a total system of pre-payment for the cost of health care, and urging the Board not to barter or sell its beds but, instead, transfer them to where they are needed; and The Chairman having closed the Board hearing; the Board members having expressed their opinions on the testimony received, and the directions the Board should take; IT IS BY THE BOARD ORDERED THAT: 1 . The Health Services Director is directed to prepare a plan for marketing the Contra Costa Health Plan more aggressively, and to present such a report to the Board by mid to late August, 1983; 2. The Health Services Director be directed to describe how a proposed shared-risk pool might be implemented, and to report his findings and recommendations to the Board by mid to late August; 3. The Resolution presented by Supervisor Torlakson relating to the need to give special attention to the health care needs in east County be scheduled for discussion on August 2, 1983; 4. The County Administrator be directed to send a letter to the Executive Director, Alameda-Contra Costa Health Systems Agency, urging that the Health Systems Agency in reviewing the existing Certificate of Need applications take into consideration changing utilization patterns and future demands for services; that they conduct an analysis of the increased health care costs created by the need to borrow additional capital to finance the proposed Certificate of Need applications, and that the applications be judged in part on the basis of the provider' s expressed concern for and plans to serve indigents; 283 -3- 5. The Board consider on August 2, 1983 the proposed policy assumptions contained in the-County Administrator's letter of July 8, 1983. I hereby certify that this is a true and correct copy of an action taken and entered on the minutes of the Board of Supervisors on the date shown. ATTESTED QwL z4, /qP-3 J.v- SSON, COUNTY CLERK AND EX OFFICIO CLERK OF THE BOARD By �� - �. ¢ - Lw Deputy cc: County Administrator Health Services Director Health Systems Agency 284 T° BOARD OF SUPERVISORS //''��,�,� 'FROM: Finance Committee Con Costa DATE: July 26, 1983 Cb^ SUBJECT: APPOINTMENT OF CONTRA COSTA COUNTY PRIVATE INDUSTRY COUNCIL MEMBERSHIP SPECIFIC REQUEST(S) OR RECOMMENDATION(S) & BACKGROUND AND JUSTIFICATION That the Board APPROVE the Finance Committee's recommendations regarding the County' s new Private Industry Council (PIC) as follows: 1 ) That the Board APPOINT the twenty (20) individuals named in the attached "PIC Selection Worksheet" for the terms*' specified therein, to the Private Industry Council under Public Law 97-300, Section 102 of the Job Training Partnership Act (DTPA) , and that the Board Chairman is AUTHORIZED to execute the applicable document(s) requesting State certification of said PIC membership in the County' s Service Delivery Area (SDA) ; 2 ) That the Board DIRECT the Director, Department of Manpower Programs, to notify said PIC membership and convene the first meeting of said body on Friday, July 29, 1983 ; and 3 ) That the Board AUTHORIZE reimbursement of travel, registration and meal expenses for the herein appointed PIC members who attend the Orientation Session at Skyline College, San Bruno, California, on August 3, 1983, sponsored by the State Job Training Coordinating Council. Funds for these expenses are 100 percent federal funds. By its Order, dated June 28, 1983, the Board approved the establishment of a twenty-member PIC. The herein proposed appointments, including allotments, are in accordance with said Board Order. *Terms of Office will end on September 30 of appropriate years . 'CONTINUED ON ATTACHMENT: _ YES SIGNATURE: RECOMMENDATION OF COUNTY ADMINISTRATOR RECOMMENDATION OF BOARD COMMITTEE APPROVE OTHER SIGNATURE S : ACTION OF BOARD ON �= '�G -� APPROVED AS RECOMMENDED OTHER r VOTE OF SUPERVISORS 1 HEREBY CERTIFY THAT THIS IS A TRUE UNANIMOUS (ABSENT AND CORRECT COPY OF AN ACTION TAKEN AYES: NOES: AND ENTERED ON THE MINUTES OF THE BOARD ABSENT; ABSTAIN: OF SUPERVISORS ON THE DATE SHOWN. cc: County Administrator ArrEsTED _ a(I, , If ?-3 Auditor-Controller JOR. OLASSON, COUNTY CLERK Manpower Programs AND EX OFFICIO CLERK OF THE BOARD Private Industry Council n BY� Z�zL�O„�srr .DEPUTY 0 �j PIC SELECTION WORKSHEET Category Name Term I yr• fir'. Business : 1. Serafino Bianchi X 2. Roy Elliott X 3. Richard Fidler X 4, David Gilbert X 5, Barbara Guise X 6. Willard Milligan X 7. Robert Mimiaga X g. J. Kent Murray X g, Joseph Nusbaum X 10. William Sharkey X 11 . Barbara Shaw X 12. Paul Witkay X Education: 1. Harry Buttimer X 2. Ronald Stewart X Labor: 1. David Platt X 2. M. Colleen Swift X Rehabilitation: 1. Robert Mathews X Community-Based Organization I. Annell Grove X Economic Development: 1. Steven Giacomi X Public Employment Service: 1. 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None ABSENT: Supervisor.- Powers ABSTAIN: None SUBJECT: Iq the Matter of Award of Contract for Beloit Avenue Road Restoration at -Los Altos Drive, Project No. 0671-6R6310-82, Kensington Area. Bidder Total Amount Bond Amounts Dawson and J.R's Construction, $16,180.00 Labor & Mats. $85090.00 Inc. Faith. Perf. $16,180.00 P. 0. Box 8414 Emeryville, California 94662 C and G Contractors Gallagher„ and Burk, Inc. B and B Paving, Inc. Ransome Company 0. C. Jones and Sons Sarott Construction Co. The above-captioned project and the specifications therefor being approved, bids being duly invited and received by the Public Works Director; and The Public Works Director recommending that the bid listed first above is the lowest responsible bid and this Board concurring and so finding; IT IS BY THE BOARD ORDERED, that the contract for the furnishing of labor, and materials for said work is awarded to said first listed bidder at the listed amount and at the unit prices submitted in said bid; and that said contractor shall present two good and sufficient surety bonds as indicated above; and that the Public Works Department shall prepare the contract therefor. IT IS FURTHER ORDERED that, after the contractor has signed the contract and returned it together with bonds as noted above and any required certificates of insurance or other required documents, and the Public Works Director has reviewed and found them to be sufficient, the Public Works Director is authorized to sign the contract for this Board. IT IS FURTHER ORDERED that, in .accordance with the project specifications and/or upon signature of the contract by the Public Works Director, any bid bonds posted by the bidders are to be exonerated and any checks or cash submitted for bid security shall be returned. 1 oM11y Brat tl+b a hua aad oornetoopy of an aofbn taken and entered on**ndnuMa of Vo Board of tupervbore on Vw data drown. ATTO:fm JUL 2 6 �q�__.._.r.._ JJL OLUON,COUNTY CLOW ad as oflis{ao Clerk of 00 Be” Orig.Dept.: Public Works Department BY� ,,,.,,,ppuly Design and Construction Division cc: County Administrator County Auditor-Controller Public Works Director Design and Construction Division Accounting Division Contractor DC.BELOITAVEBO.BW 2 9 9 THE BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Adopted this Order on July 26, 1983 by the following vote: . AYES: Supervisors Fanden, McPeak, Torlakson, Schroder NOES: . None ABSENT: Supervisor Powers ABSTAIN: None SUBJECT: Irl the Matter of Award of Contract for Drainage Area 44B Outfall , Line A, Phase II, Plan B. Project No. 7547-6D8590-83, Pleasant Hill Area. Bidder Total Amount Bond Amounts KIP, Inc. $134,025.00 Labor & Mats. $67,012.50 6940 Tremont Road Faith. Perf. $134,025.00 Dixon, California 95620 W. R. Thomason, Inc. Edward J. Pestana Mountain Cascade The above-captioned project and the specifications therefor being approved, bids being duly invited and received by the Chief Engineer; and The Chief Engineer recommending that the bid listed first above is the lowest responsible bid and this Board, as the governing body of the Contra Costa County Flood Control and Water Conservation District, concurring and so finding; IT IS BY THE BOARD ORDERED, that the contract for the furnishing of labor, and materials for said work is awarded to said first listed bidder at the listed amount and at the unit prices submitted in said bid; and that said contractor shall present two good and sufficient surety bonds as indicated above; and that the Flood Control District shall prepare the contract therefor. IT IS FURTHER ORDERED that, after the contractor has signed the contract and returned it together with bonds as noted above and any required certificates of insurance or other required documents, and the Chief Engineer has reviewed and found them to be sufficient, the Chief Engineer is authorized to sign the contract for this Board. IT IS FURTHER ORDERED that, in accordance with the project specifications and/or upon signature of the contract by the Chief Engineer, any bid bonds posted by the bidders are to be exonerated and any checks or cash submitted for bid security shall be returned. 1 hereby certify that this la a true.and correetcopy of an act.lon taken and crtc:ed on the minutes of the Board of Superclr.c:c •:-i th.c data ahown. �JUL 2 61983 C-'!" 'YY CLERK orad ex ot9:c : �: :c t'J.3 Board Orig.Dept.: Public Works Department Design and Construction Division , Deputy cc: County Administrator County Auditor-Controller Public Works Director, Chief Engineer Design and Construction Division Accounting Division Contractor DC.DA44BPHASEIIBO.BW 300 , THE BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Adopted this Order on July 26, 1983 , by the following vote: AYES: Supervisors Fanden, McPeak, Torlakson, Schroder NOES: None ABSENT: Supervisor Powers ABSTAIN: None RESOLUTION NO. 83/ 915 SUBJECT: In the Matter of Approving Plans and Specifications for Las Trampas Creek Bank Repairs at Moraga Boulevard, Proj. No. 7505-6F7752-83, Lafayette Area WHEREAS the Chief Engineer has filed this day with the Board of Super- visors, as the Governing Body of the Contra Costa County Flood Control and Water Conservation District, Plans and Specifications for Las Trampas Creek Bank Repairs at .Moraga Boulevard; and WHEREAS the general prevailing rates of wages, which shall be the minimum rates paid on this project,have been filed with the Clerk of this Board and copies will be made available to any interested party upon request; and WHEREAS the estimated contract cost of the project is $106,000; and WHEREAS this emergency project is considered exempt from the requirements of CEQA in accordance with Section 15071(a) "Emergency Projects", of the California Environmental Quality Act. IT IS BY THE BOARD RESOLVED that said Plans and Specifications are hereby APPROVED. Bids for this work will be received on Thursday, August 18, 1983 at 2:00 p.m. , and the Clerk of this Board is directed to publish Notice to Contractors in accordance with Appendix Section 63-22 of the West ' s Water Code, inviting bids for said work, said Notice to be published in CONTRA COSTA SUN. 1 herby certify that this Is s true and cornet copy of an aotlon taken and entered on the minutes of the Board of Supervisors on the date shown. ATTESTED: UL 2 61963 J.R.OLSSON, COUNTY CLERK and ex officlo Clerk of tM Board Orig.Dept.: Public Works Design/Construction cc: County Administrator Auditor-Controller Public Works Director Design/Construction Accounting RESOLUTION NO. 83/ 915 bo:tl.BkRprsLTramCk.t7 Orig. Dept.: cc: 301 'THE BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Adopted this Order on July 26, 1983 , by the following vote: AYES: Supervisors Fanden, McPeak, Torlakson, Schroder NOES: None ABSENT: Supervisor Powers ABSTAIN: None SUBJECT: In the Matter of Approving Plans and Specifications for Alhambra Creek Bank Repairs at Sonora Court Proj. No. 7505-6F7750-83 Martinez Area RESOLUTION NO. 83/917 WHEREAS the Chief Engineer has filed this day with the Board of Super- visors, as the Governing Body of the Contra Costa County Flood Control and Water Conservation District, Plans and Specifications for Alhambra Creek Bank Repairs at Sonora Court; and WHEREAS the general prevailing rates of wages, which shall be the minimum rates paid on this project, have been filed with the Clerk of this Board and copies will be made available to any interested party upon request; and WHEREAS the estimated contract cost of the project is $151,000; and WHEREAS this emergency project is considered exempt from the requirements of CEQA in accordance with Section 15071(a) "Emergency Projects", of the California Environmental Quality Act. IT IS BY THE BOARD RESOLVED that said Plans and Specifications are hereby APPROVED. Bids for this work will be received on Thursday, August 18, 1983 at 2:00 p.m. , and the Clerk of this Board is directed to publish Notice to Contractors in accordance with Appendix Section 63-22 of the West ' s Water Code inviting bids for said work , said Notice to be published in CONTRA COSTA SUN. 1 hereby or"that this Is a true and correct copy of an action taken and eM!mred on the minutes of the Board of Supervisors on the date shown. Orig.Dept.: Public Works ATTESTED: JUL 2 61983 Design/Construction J.R. OLSSON, COUNTY CLERK and ex officlo Clark of Uw Board cc: County Administrator Auditor-Controller a Public Works Director By ,ppnty Design/Construction Accounting RESOLUTION NO. 83/' 917 bo:tlAlhCrk.t7 302 THE BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Adopted this Order on July 26, 1903 , by the following vote: AYES: Supervisors Fanden, McPeak, Torlakson, Schroder . NOES: None ABSENT: Supervisor Powers ABSTAIN: None RESOLUTION NO. 83/916 SUBJECT: In the Matter of Approving Plans and Specifications for Alhambra Creek Bank Repairs near Wanda Way, Proj. No. 7505-6F7751-83, Martinez Area WHEREAS the Chief Engineer has filed this day with the Board of Super- visors, as the Governing Body of the Contra Costa County Flood Control and Water Conservation District, Plans and Specifications for Alhambra Creek Bank Repairs near Wanda Way; and WHEREAS the general prevailing rates of wages, which shall be the minimum rates paid on this project,have been filed with the Clerk of this Board and copies will be made available to any interested party upon request; and WHEREAS the estimated contract cost of the project is $19&,000; and WHEREAS this emergency project is considered exempt from the requirements of CEQA in accordance with Section 15071(a) "Emergency Projects", of the California Environmental Quality Act. IT IS BY THE BOARD RESOLVED that said Plans and Specifications are hereby APPROVED. Bids for this work will be received on Thursday, August 18, 1983 at 2:00 p.m. , and the Clerk of this Board is directed to publish Notice to Contractors in accordance with Appendix Section 63-22 of the West ' s Water Code, inviting bids for said work, said Notice to be published in CONTRA COSTA SUN. I herby oerllty that this Is a true and corraotoopy of an action taken and entered on the minutes of the Board of supervisors on the date shown. ATTESTED: - J U L 2 61983 J.R. OLSC��H, irOUNTY CLERK and ex officio Clerk of the Board Orig.Dept.: Public Works Design/Construction cc: County Administrator Auditor-Controller Public -Works Director Design/Construction Accounting RESOLUTION NO. 83/ 916 bo:TL.A1hCkWndaWy.t7 Orig. Dept.: cc: 303 THE BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Adopted this Order on July 26 . 1983 , by the following vote: AYES: Supervisors Fanden, Torlakson, Schroder NOES: None ABSENT: Supervisors Powers $ McPeak ABSTAIN: SUBJECT: Appeal of B $ D Company from Denial of Rezoning Application 2463-RZ , Discovery Bay Area , This Board on May 17, 1983, having considered the request of B $ D Company for reconsideration of its appeal from denial of application 2463-RZ to rezone land in the Discovery Bay area, and having adopted the order attached hereto and by reference incorporated herein; and Supervisor Torlakson this day having reported that the Planning Commission is scheduled to hold a hearing later this day on the general plan designation only, that it was the intent of the Board's order of May 17, 1983, that both issues (general plan and zoning) be considered at the same public hearing, and having . therefore recommended that the Director of Planning be instructed to reschedule and renotice the hearing accordingly; IT IS BY THE BOARD ORDERED that the recommendation of Supervisor Torlakson is APPROVED. I hereby car"that this is a true and correct copy of an action taken and entered on the minutes of the Board of Supervisors on the date shown. ATTESTED: 3' J.R.01.316, COUNTY CLERK and ex officlj Clerk cf the Board g cu�o�ao.Deputy CORRECTED COPY! . PLEASE DESTROY PREVIOUS ISSUE Orig. Dept.: Clerk of the Board cc: B & D Company c/o Attorney Stoddard Planning Director Public Works Director County Couns 1 f THE BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Adopted this Order on May 17, 1983 , by the following votes AYES: Supervisors Powers, Fanden, Torlakson and Schroder NOES: Supervisor McPeak ABSENT: None ABSTAIN: None . SUBJECT: Request for Reconsideration of Board Denial of Rezoning . Application 2463-RZ Filed by B & D Company, -Discovery Bay Area The Board on May 3, 1983 having denied the appeal of the B & D Company from the County Planning Commission denial of rezoning application 2463-RZ to rezone land in the Discovery Bay area, and having initiated a General Plan review with the request that the Planning Commission consider an appropriate general plan designation for the property and zoning consistent with that designation; and The Board having received a May 13, 1983 letter from Candice E. Stoddard, attorney representing the B & D Company, requesting that the Board reconsider its May 3 decision denying the Company's appeal, alleging that pertinent factual information was not brought to the Board's attention; and Supervisor Torlakson having expressed the opinion that additional zoning options should be considered for the B & D Company property, and having recommended that the matter be referred back to the Planning Commission to consider in conjunction with its General Plan review for the area; and Supervisor McPeak having stated that in her opinion no new evidence was presented to warrant reconsideration of the appeal denial; IT IS BY THE BOARD ORDERED that the recommendation of Supervisor Torlakson is APPROVED and that the appeal of the B & D . Company on rezoning application 2463-RZ is REFERRED back to the Planning Commission for review together with its review of an appropriate general plan designation for the subject property and zoning consistent with that designation. 1 Mehr eef tr tf►af thk to•Inn andeorrecfoM of an action taken and entered on the minutes of tM Board of Supendsors on the data ahem. ATTESTED: 17. /f�3 J.R.OLS=N,COuf4T'Y CLERK and ex officio Ckrk of the BOOrd By Deputy cc: B & D Company Candice Stoddard County Planning Commission Director of Planning Public Works Director 305 ,�7- /3 THE BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Adopted this Order on July 26, 1983 , by the following vote: AYES: Supervisors Fanden, McPeak, Torlakson and Schroder NOES: None ABSENT: Supervisor Powers ABSTAIN: None SUBJECT: CATV Community Access Channels Supervisor Torlakson having commented that he was of the opinion that it would be appropriate to review the money available in the CATV Community Access Fund and to review what might be done to assist the ad hoc CATV Committee on Community Access in its efforts for local programming, and having suggested that it might be helpful to hire a consultant to work with that committee and the Public Works staff; IT IS BY THE BOARD ORDERED that the proposal for a con- sultant to assist the aforesaid ad hoc Committee is REFERRED to the Finance Committee (Supervisors Torlakson and McPeak) . 1 hereby certify that thiafa�fruea,:iwrgaeteopy of an action taken and entered on the minutes of Ow Board of Supen dsors on the date shown. ATTESTED: q3.,. J.R. OM J, C U�TY CLER, and ex officio Clark of the Board BY cc: Finance Committee members Public Works Director County Administrator X06 At 11 : 30 a.m. the Board recessed to meet in Closed Session in Room 105 , the James P. Kenny Conference Room, County Administration Building , Martinez , CA to discuss a litigation matter. At 11 :45 a.m. the Board reconvened in its Chambers and the Chairman announced that the Board would recess for lunch and reconvene for the afternoon session at 2 p.m. 307 THE BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Adopted this Order on ' July_2_6, 1983 �, by the following vote: AYES: Supervisors Fanden, McPeak, Torlakson and Schroder NOES: None ABSENT: Supervisor Powers ABSTAIN: None SUBJECT: Application of Desco Investment Group (2555-RZ) to rezone land from M-29 and R-15 to P-1, Wayside Associates/Paraty Investors, owners, Pleasant Hill BART Station area. This being the time for hearing on the recommendation of the County Planning Commission on the application filed by Desco Investment Group (2555-RZ) to rezone land from Multiple Family Residential District (M-29) and Single Family Residential District (R-15) to Planned Unit District (P-1) , Wayside Associates/Paraty Investors, owners; and Mr. Harvey Bragdon, Assistant Director of Planning, having described the property and the applicant' s plans for a 3-phase develop- ment, and having advised that the California Environmental Quality Act requirements for this application have been adequately covered by the Environmental Impact Report prepared for the Pleasant Hill BARTD Station Area General Plan Amendment and Specific Plan; and Mr. Bragdon having recommended that in conjunction with consideration of the subject rezoning, the Board initiate an amend- ment to the Specific Plan to allow for limited variances, such as for set backs; and The Chairman having declared the hearing opened and Louis Rozenfeld, President of Desco Investment, Inc. , having appeared and having commented on the proposed project and having urged the Board to approve the rezoning and to initiate an amendment to the Specific Plan; and Supervisor McPeak having commented on the progress of the phases of planning for this area, and having recommended approval of the above application and the initiation of variance procedures for the Specific Plan; IT IS BY THE BOARD ORDERED that the recommendation of Supervisor McPeak is APPROVED and that rezoning application 2555-RZ is APPROVED subject to conditions of approval attached hereto as Exhibit A. IT IS FURTHER ORDERED that Ordinance No. 83-30 giving effect to the aforesaid rezoning is INTRODUCED, reading waived and August 9, 183 is set for adoption of same. IT IS FURTHER ORDERED that an amendment to the Pleasant Hill BARTD Station Area Specific Plan be initiated to allow for a limited variance procedure. 1 twreby ow"that this Is a true and correct copy 01 an&Coon taken and entered on the minutes of th% Board of Supervisors on the date shown. 17 cc: Desco Investment Group ATTESTED: , Director of Planning J.R. OLS� N, COUNTY CLERK Public Works Director and ex officio Clerk of the Board County Counsel County Assessor ` ;..:;,.. ;. . . .. BY r DelSi:tA 3 oYJ CONDITIONS OF APPROVAL FOR 2555-RZ 1. This approval is based on the revised Preliminary Development Plan received by the Planning Department July 13, 1983 subject to further review at the time a Final Development Plan is submitted for review and approval: Additional requirements, conditions and/or modifications may be specified following the review of the Final Development Plan. The conditions in this approval serve to give direction to the applicant in the preparation of the Final Development Plan. 2. Development shall be in general accordance with the following exhibits as modified by the conditions listed below and subject to the Final Development Plan review process. Exhibit 411 - Revised Preliminary Site Development Plan. Exhibit 412 - Typical Unit Plans for Phase I. Exhibit 413 - Typical Prototype Unit Plans for Phase 2 & 3. Exhibit 414 - Project Elevation and Section Plan (2 sheets). 3. The total number of units in the project shall not be less than an average of 35 dwelling units per net acre. 4. The Final Development Plan shall indicate the placement, grading and architectural style, including roof plans .and elevations of buildings. Plans for the units may be modified based on grading. Layout or massing of building with review of the Final Development Plans. Final Development Plan review shall assure provision for visual privacy to indoor residential uses and reasonable solar access to all major public and/or private open areas. 5. Project elevations shown in Exhibit 414 serve as a basis for the approved architectural style. Individual buildings shall be designed to be compatible in appearance by utilizing common and/or compatible exterior materials, colors and/or detailing. 6. The project shall include a unified landscaping and pedestrian circulation scheme . similar to that shown on Exhibit 411. A Preliminary Landscaping Plan shall be submitted at the Final Development Plan application stage, with final landscaping and irrigation plans being subitted prior to issuance of any building permits within each phase. Platanus Acerifolia - (london plan) trees shall be planted along the Coggins Drive frontage and along the southerly property line adjacent to the required right-of-way. The trees shall be generally spaced 221 - 30' apart. 7. The applicant is required to either: A. Participate in an approved areawide assessment district; or B. Pay all project wide fees associated with the Specific Plan prior to issuance of any building permit or recordation of any final map unless specifically required to be paid by unit or by phase. Actual costs will be specified in the. Final Development Plan approval conditions. 2555-RZ pg. 2 8. The project shall provide 0.75 parking spaces per bedroom (but no less than 1 space per unit or more than 1.5 spaces per unit averaged throughout the project). The minimum required parking must be covered. Guest parking shall be clearly defined. 9. A preliminary draft for Covenants, Conditions and Restrictions, Articles of Incor- poration and By-Laws for mandatory homeowners' association shall be submitted for review and approval and recordation prior to the issuance of any building permits or the recordation of any final map. These documents shall provide for establishment, ownership and maintenance of the common open space and parking, fire protection, fencing, private streets, recreational facilities and drainage maintenance. 10. Street names shall subject to review and approval of the Director of Planning. 11. All utilities shall be placed underground. Location of all utility meters shall be shown on the preliminary landscaping plan submitted with the Final Development Plan. Adequate screening shall be provided. If necessary, landscaping changes or addition may be required based on field inspections. 12. If archaeologic materials are uncovered during grading, trenching or other on-site excavation, earthwork within 30 meters of these materials shall be stopped until a professional archaeologist who is certified by the Society for California Archaeology (SCA) and/or the Society of Professional Archaeology (SOPA) has had an opportunity to evaluate the significance of the find and suggest appropriate mitigation measures, if they are deemed necessary. 13. Any phasing of the project shall be subject to approval with the Final Development Plan and Tentative Subdivision Map. 14. The project shall conform to all requirements of the Pleasant Hill BART Station Specific Plan. In addition to the conditions listed herein, the following criteria shall be met: A. 350 sq. ft. per unit usuable open space net acreage devoted to landscaping, private yards, courtyards or exterior pedestrian circulation shall be provided. B. 15' and 20' setbacks and 2:1 stepped back profile above three stories along the northern and western boundaries abutting existing developments shall be pro- vided. C. 20' setbacks and an additional 20' setback over three stories shall be observed along Coggins and the new 60' right-of-way on the south property line. 15. Sewage disposal serving the properties concerned in this application shall be provided by the Central Contra Costa Sanitary District. The sewers located within the boundaries of the properties concerned shall become an integral part of and subject to the requirements of the Central Contra Costa. Sanitary District's sewerage collection system. 16. Water supply serving the properties concerned shall be by the Contra Costa County Water District. Such water distribution system, located within the boundaries of the 2555-RZ pg. 3 properties concerned in the application, all become an integral part of the CCCWD overall water distribution system. Each individual living unit should be served by a separate water connection. 17. Department of Health Services - Public Health's approval of plans is required for any proposed pool, spa pool or swimmer's restrooms, shower or dressing facilities prior to construction or installation. The applicant should contact that department if he has any questions. 18. Comply with the requirements of the Public Works Department as follows: A. The Final Development Plan and Tentative Map will be required to conform to the provisions of the County Ordinance Code, Titles 9 & 10 and the following: 1. Construct an 8 foot sidewalk, necessary pavement widening, curbs, longitudinal and transverse drainage along the frontage of Coggins Drive. 2. Construct a paved turnaround at the end of the proposed private road. 3. Underground all utility facilities. 4. Install street lights on Coggins Drive and apply for annexation to the appropriate lighting district for maintenance of same. B. The Final Development Plan and Tentative Map should be required to implement the Pleasant Hill BART Specific Plan goals as follows: 1. Construct 28 foot roadway and frontage improvements within a 38' foot right-of-way connecting Coggins Drive with Wayside Lane along the development's southern property line. 2. Dedication of the County of a 38-foot right of way between Coggins Drive and Wayside Lane along the development's southern property line in conjunc- tion with Phase I and designate a 30-foot roadway reserve along the southern property line between Wayside Lane and the property's westerly property line. This reserve shall include horizontal transition curves designed to a minimum of collector street standards. The westerly tangent point shall be located approximately 1,900 feet from the west property line. The need to dedicate this reserve and the final alignment of the planned future 60-foot right of way intended to serve Sub Area 3 of the Pleasant Hill BART Specific Plan Area should be resolved prior to the development of Phase II of 2555-RZ. 3. Construct frontage improvements consisting of an eight foot sidewalk, curb, gutter and drainage modifications along the western frontage of Coggins Drive and the northern frontage of the access road connecting Coggins Drive and Wayside Lane. 4. Mitigate the impacts of traffic generated by this project by construction off-site road improvements or contributing toward a Pleasant Hill BART 2555-RZ pg. 4 Specific Plan Area Road Improvement Fund. This project's off-site road improvement responsibility is estimated at $115,000. C. Pay the required fee for Drainage Area 44B plus an additional 50% surcharge. D. Prior to the filing of any Final Map on the property, obtain the abandonment of Wayside Lane through the project. 19. Upon adoption of a procedure for variances to any of the criteria established by the Specific Plan the conditions contained herein shall not preclude the applicant from making such requests at the time of Final Development Plan submittal and review. DE:ed9asub 7/25/83 y r THE BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Adopted this Order on July 26, 1983 , by the following vote: AYES: Supervisors Fanden, McPeak and Torlakson NOES: Supervisor Schroder ABSENT: Supervisor Powers ABSTAIN: None SUBJECT: Appeal of H. F. Amsen from Board of Appeals denial of application for Minor Subdivision 2-83. This being the time to hear the appeal of H. F. Amsen, applicant and owner , from the Board of Appeals denial of applica- tion for Minor Subdivision 2-83 to divide 11. 7 acres into two par- cels in a General Agricultrual District (A-2) , said property being located on the north side of Balfour Road, approximately 1, 750 feet east of Sellers Avenue, in the Brentwood area; and Mr . Harvey Bragdon, Assistant Director of Planning, having described the property and having advised that the Zoning Administrator and the Board of Appeals had denied the application as the proposed minor subdivision would be inconsistent with the East County General Plan which calls for a minimum of 10-acre parcels; and Mrs. A. Amsen, applicant and owner , having appeared and urged the Board to grant the appeal; and Ms. Tiny Bettencourt, representing the East Diablo Planning Area Committee, having advised that EDPAC had voted in favor of the applicant because the land is presently zoned A-2 which permits minimum 5-acre parcel size; and Supervisor Torlakson having commented on the provisions of the East County General Plan, the current zoning designation, the provisions of the "Ranchette Study," ' and the need to preserve prime agricultural land; and Supervisor Torlakson having recommended that, in confor- mance with the provisions of the East County General ,Plan, the Board uphold the Zoning Administrator and the Board of Appeals and deny the appeal; and Supervisor Schroder having stated that he would vote against the motion because he was of the opinion that the regula- tions are unclear ; IT IS BY THE BOARD ORDERED that the decision of the Board of Appeals is UPHELD, and the appeal is DENIED. I hereby eerlMy that this Is a trio and cortectcopy o1 an action taken and entered on the minutes of dw Board of Supervisors on tho date shown. ATTESTED: J.H. 07E.5 °a; CTUNTY CLERK and ex of the Board 8y + deputy cc: Mr. & Mrs. H. F. Amsen Director of Planning County Counsel 3o � And the Board adjourns to meet in regular session ona / at ��'�c, yr, . in the Board Chambers, Room 107, County Administration Building, Martinez, CA. kRnhert . hroder Chair ATTEST: J. R. OLSSON, Clerk A-a'� 4--O-Lit Geraldine Russell, Deputy Clerk 310 .� -