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II. COMPANY DETAILS �j <br />I�s4//o/a) �f/0 _ - i77/1,0 <br />1. NAME OF AMBUUNCE SERVICE: S O / c 7i7 C.- <br />MAILING ADDRESS: -----? 7 ®, 47d (D,M J ,!fr <br />CITY /5/Vie-Ig COUNTY .17/0 J/�i�ic/ /C/ <br />`�11e7(_, <br />ZIP CODE: 3�f 6, BUSINESS PHONE: 772_ - 770--/ao <br />2. TYPE OF OWNERSHIP(i.e. Private, Government, Volunteer, Partnership, <br />etc.): <br />C'C•eC._.- <br />3. MANAGER'S NAME: ��il!.0 /.15;74 4) <br />ADDRESS: ° 7730 ii ---1)7)41 44,06: <br />PHONE #: v4x 'k -,//,z <br />'170 -- /qw0 <br />4. PROVIDE NAME OF OWNER(s) OR LIST ALL OFFICERS, PARTNERS, <br />DIRECTORS, AND SHAREHOLDERS, IF A CORPORATION (attach a <br />separate sheet if necessary): <br />NAME <br />JT -74,17 644dr- <br />ADDRRE SPOSITION <br />373ffo- is /20, <br />If)c-cr ig/dr: Milr, Pacf,VeRYT/ C& -r) <br />7 COO <br />5. PROVIDE NAMES AND ADDRESSES OF AT LEAST THREE (3) LOCAL <br />REFERENCES <br />NAME ADDRESS PHONE# <br />4//i4 <br />U:\Beth\Beth Casano EOC\COPCN\RENEWAL PACKETS\COPCN Application.doc <br />2 <br />90 <br />