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T-IR <br /> F orange County Fire Authority OM210.05 <br /> Request for Special Event Paramedic Services Attachment 1 <br /> 'Lr"0 <br /> . Be Completed by Applicant <br /> • Advance payment for 2 FF/PM for 4 hour minimum is required. Credit card payment may be made by contacting Accounts <br /> N Receivable at(714)573-6342. Check payment should be mailed to PO Box 51985 Irvine,CA 92619-1985 <br /> °1 a Requests for service with less than two weeks notification will be assessed an accelerated processing fee of$100 <br /> • Cancellation with less than 24 hours notice will be assessed a fee of$100 <br /> fl • Applicant will provide and maintain adequate access to potential patients,as well as ingress/egress from the venue. <br /> • Applicant understands that the Fire Authority does not arrange for,or provide for ambulance transportation services. <br /> a os • After the event,the applicant will be billed for the actual hours worked in excess of the 4 hour minimum already paid. This <br /> w a includes hours worked at the event,any standby hours at the hospital,1 hour for set up,and 1 hour for demobilization. The <br /> hourly rate billed will vary depending on OCFA's staffing availability. <br /> V -0 <br /> EL + Effective 3/1/17,a 2.45%convenience fee will be charged for payments using credit or debit cards. The convenience fee is <br /> based on the total amount of the charge and paid directly to the service vendor. No convenience fee will be charged for <br /> payments by cash,check,or electronic check(eCheck). <br /> Business Name Contact Name <br /> City of Santa Ana-Parks,Recreation and Community Services Agency Rudy Hernandez <br /> Billing Name Billing Address <br /> c City of Santa Ana-Parks,Recreation and Community Services Agency 20 Civic Center Plaza P.O.Box 1988 <br /> m <br /> Santa Ana,CA 92702 <br /> cL <br /> Billing E-mail <br /> Rhernandez5@5anta-ana.org <br /> ai <br /> m Business Phone Business FAX <br /> (714)571-4229 N/A <br /> Applicant Signature Date <br /> 09/02/2025 <br /> Event Name Event Location <br /> Fiestas Patrias Festival and Parade Downtown Santa Ana(between Main st.and French Street) <br /> o Event Description Celebration of Hispanic and Latino communities on #of Participants #of Spectators <br /> 'Z; September 13-14.2025 Open to all,the free weekend-long festivities include 1,00o 70,000-80,000 <br /> E a parade and street fair,live music,carnival rides and more—all <br /> commemorating Mexican independence and celebrating the various Latin <br /> American communities that reside throughout Orange County. <br /> Date(s) <br /> w Saturday,September 13 and Sunday,September 14,2025 Paramedic Unit Paramedic Unit <br /> Start Time:12p(09/13&09/14) End Time:10p(9/13)9p(9/141 <br /> Name of person(s)for paramedic crew to report to at the event site Event Contact Phone <br /> Rudy Hernandez,Patty Martinez,Samira Meza,Tim Pagano,Hawk Scott �714-318-021S <br /> To be completed <br /> Conditions of Use <br /> a Required Notifications Resources Assigned <br /> aL <br /> n <br /> O Total Billable Hours Additional Fees <br /> ®Accelerated processing: $100 <br /> X(2) FF/PM per hour($155.02—FY 25/26) ❑Late cancellation: <br /> Date Application Received Received By(Name/Fmp ft) Date Processed Processed By(Name/Emp#) <br /> Payment <br /> c <br /> m <br /> c <br /> �`- Total Amount 620.08 ❑ Credit Card(Last 4 digits): ❑Check#: Paid By: <br /> Operatsons Point of Contact Date Notified <br /> Orange County Fire Authority-Cost Accounting Manager <br /> 1 Fire Authority Rd,Irvine,CA 92602 <br /> Office:714 573-6316 1 FAX:714 369-8834 Revised 2/08/21 <br />