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HomeMy WebLinkAbout182-02 RESOLUTION• RESOLUTION NO. 182-02 T A RESOLUTION GRANTING A CERTIFICATE OF PUBLIC CONVENIENCE AND NECESSITY TO PARTY TIME PONIES FOR THE OPERATION OF A NON -MOTORIZED TRANSPORTATION SERVICE. BE IT RESOLVED BY THE CITY COUNCIL OF THE CITY OF FAYETTEVILLE, ARKANSAS: Section 1. That the City Council of the City of Fayetteville, Arkansas hereby grants a Certificate of Public Convenience and Necessity to Party Time Ponies for the operation of a Non -Motorized Transportation Service. PASSED and APPROVED this 25,1, day of November 2002. By: APPROVED: By �117Jflc4 A HT EOODRUFF,C'City Clerk DAN COODY, M�• ME OF FILE: S REFERENCE: Item # Date • Resolution No. 182-02 Document • 1 11/25/02 Resolution No. 182-02 2 11/25/02 Letter from Julie Johanson to Fay City Council 3 11/25/02 Memo to: Gary Dumas Copy of Certificate of Public Convenience & Necessity App. 11/14/02 Copy of insurance Copy of Patient History Report from Northwest Equine Svc for seven ponies Copy of Equine Infectious Anemia Laboratory Test B1859808 B1859809 B1859810 B1859812 B1859813 Copy of Receipt No 3049 -Washington County Clerk Copy of Certificate Business under Assumed Name copy of flyer copy of 8/31/02 letter to Fayetteville Animal Control copy of fax cover sheet from Dotson Glass & Mirror w/attachments:copy of fax: Dotson Glass & Mirror copy of 2002 Horse Drawn Carriage Privilege Permit App w/attachments:equine infectious anemia lab test (2) receipt Veterinary Services, Inc. (No. 007154) copy of Ord. No. 4396 w/Ex. A NOTES: • • RESOLUTION NO. A RESOLUTION GRANTING A CERTIFICATE OF PUBLIC CONVENIENCE AND NECESSITY TO PARTY TIME PONIES FOR THE OPERATION OF A NON -MOTORIZED TRANSPORTATION SERVICE BE IT RESOLVED BY THE CITY COUNCIL OF THE CITY OF FAYETTEVILLE, ARKANSAS• Section 1. That the City Council of the City of Fayetteville, Arkansas hereby grants a Certificate of Public Convenience and Necessity to Party.. Ti, n e Ponies for the operation of a Non -Motorized Transportation Service, =' PASSED and APPROVED this 25th day of November 2002--- AN 002 AN GOODY, Mayor DRUFF, City Clerk PARTY TIME PONIES• Jack and Julie Johansen 479-267-2101 12395 W. Hwy 62 479-957-7095 Farmington, Arkansas 72730 November 25, 2002 Fayetteville City Council 113 W. Mountain Street Fayetteville, Arkansas 72701 Re: Pony Rides on the Square Dear Council Members: Party Time Ponies would like the opportunity to provide quality pony rides on the square during the Christmas season. My husband and I are the original owners of Party Time Ponies and operated the rides without incident from 1994 through 1999. In August of this year we retained ownership of the business again. We have invested substantially in new Christmas costumes for the ponies which we believe will add to charm and festive spirit found on the square during this time of year. We are proposing to operate four ponies on a carousel at the northeast corner of the square. We have provided all the necessary documentation to the City Clerk's office for a total of six animals. Two animals will be used as alternates as needed. We are also asking the City Council to waive the helmet provision in the ordinance. We are unable to comply with this section due to health concerns, such as the transmittal of lice from one child to another. We respectfully request a Certificate of Public Convenience and Necessity and a waiver from the requirement of the use of helmets. Sincerely, Julie Johansen Owner • • • August 31, 2002 To: Fayetteville Animal Control Fayetteville City Council Fayetteville Parks and Recreation Re: Proposal from Partytime Ponies For the Lights of the Ozarks Festival Over the past several years the Lights of the Ozarks has been a major winter attraction for Northwest Arkansas and the Fayetteville Area. The Partytime Ponies has continued to be part of this Holiday celebration. Through the many seasons that the Ponies have been on the Fayetteville Square, we have been pleased to be part of this wonderland of lights. As founders of the Partytime Ponies we sold the business three years ago. In mid-August the Pony business was returned to us. As new and former owners we would like to again be part of the festivities at the Lights of the Ozarks this 2002 — 2003 Holiday Season and beyond. It is to our understanding that there are new laws, rules, and regulations to follow since our direct involvement with this business three years ago. Our goal has always been to have a safe and fun environment for the children, adults, and for the ponies. We plan to continue that same environment for our customers and staff. We are constantly looking for ways to improve the safety of our young inexperienced riders. Historically, during the Lights of the Ozarks Festival, we have led the ponies around the Square with the rider enjoying the beautiful lights and culture the Square offers. This has become a tradition for many families for the Holiday Season. Many children are repeat riders during the course of the six-week period. Some parents venture many miles to our area looking for the "Ponies on the Square". Many children know their pony by its name and request their favorite one. During these rides the ponies are exposed to moving cars, cars backing out, cameras flashing, loud sounds from moving equipment, crackling from speakers, children running from behind, skate boards, baby carriages, leashed and unleashed dogs, and on windy nights a variety of containers blowing in the wind. Though none of these conditions are natural to horse environments, the ponies have handled them all quite well. It is our understanding, now, that when a pony is led with a rider, as rides are offered to the general public, the rider must wear some kind of head protection. Though we are not opposed to such an ordinance, health and sanitation issues should be addressed and considered. Certainly a number of these helmets would be required. Pony riders vary in size from infant to about ninety pounds. During the winter months, some children will be wearing hats, scarves, and etc. to protect themselves from the cold. With such garments, the helmets would not fit properly or as securely. Removal of these garments would only encourage the onset of illness Since most riders would not bring their own helmet, helmets would be changed from one rider to another. With the winter season we could see problems with lice, or other diseases that move from human to human. If there were such a spray to disinfect a nder's helmet, during a winter's night, the spray would/could turn ice inside the helmet. This could lead to wet heads, sick kids, and very unhappy adults. Through the years the numbers of riders have increased, as have the numbers of ponies that have been used on busy nights. If we take into consideration a busy night with six ponies, pedestrian traffic becomes very congested on an already congested city street with moving traffic. We can easily have twenty-four people and six horses mixing with drivers that not always pay attention to their driving, this is a potential for a very dangerous situation. Parking on the Square is a limited commodity. Many nights we would wait for cars to move in order to load passengers onto the ponies in the parking area around the square out of the line of traffic. Many nights the cars do not move all night long making it difficult to load the ponies from a consistent spot There has always been a carriage route around the square. Many nights we loaded passengers in this lane causing even more congestion at those intersections with cars and carriages. • • Not having a serious accident in these conditions through those years, it is my belief the handlers and the ponies have done exceptionally well at diverting an accident both of people and horses. In effort to improve this environment for everyone, I would like to propose the following solution. It is our desire to set a pony ring on an area for the season. The area required to operate the pony ring is a twenty foot by twenty foot square. A white PVC pipe fence would surround this area. The fence and the ring would be attached to the ground for stabilization and security. Wood shavings would cover the ground under the ring where the ponies walk and ease in removing any pony waste. The wood savings would be removed nightly in case of rain, snow, or inclement weather. The fence would be decorated in holiday fashion to enhance the decor of the square Because of the area required to operate the ring and attach it to the surface of the parking area, we are asking to use or possibly rent enough space to accommodate the ring for the entire Lights of the Ozarks Festival. Although we do not operate the pony rides during rain, snow, wet conditions, or unreasonably cold weather, we would still occupy that space for the duration of the season. Once the season is concluded we will repair all the holes in the surface of the pavement needed to secure our equipment as we have in the past for events such as Springfest, and Autumfest. The pony ring could be located on the east side of the Square on the approach to the Old Post Office driveway. There is sufficient space between the sidewalk and the traffic flow to accommodate the ring and not interfere with the daytime traffic flow on this street and still allow use of the Post Office Drive way for one vehicle access. During the evening hours of operation this street is usually closed. Historically the carriages load from this side of the Square. Having a designated area for the pony rides during this event would provide a safer environment for these young kids, parents, our staff, and the ponies. Using a parking area next to the sidewalk, the children could enter the fenced area from the sidewalk around the square keeping away from moving vehicular traffic. • • • Having the ponies on a pony ring would eliminate the need for helmets and their health and safety issues. Pony handlers would be closer together for added security for the children. Pony waste is contained to a smaller area and more readily dealt with. Finally the ponies and children would be in a more controlled environment we would have less opportunity for child, vehicle, and pony entanglement. It has always been a pleasure to work with the people of Fayetteville and the surrounding communities and I look forward to our future together. Let us make the coming Holiday Season one of the happiest and most joyous of all. Thank you for your consideration. Jack and Julie Johansen Partytime Ponies • • CERTIFICATE OF PUBLIC CONVENIENCE & NECESSITY APPLICATION As required In § 117.32 of the Fayetteville Code of Ordinances. ►►►►a►►►f►►►►►a►AA►:r►r►►►►►►►►►►►►►► NAME: ADDRESS: PHONE: APPLICANT DESCRIBE YOUREXPERIENCE IN THE TJAMPPOR ATION OF PASSENGERS. LIST YOUR FINANCIAL STATUS, INCLUDING THE AMOUNT OF ALL UNPAID JUDGEMENTS AGAINST YOU AND THE NATURE OF THE TRANSACTION OR ACTS GIVING RISE TO SAID JUDGEMENTS. NAME OF BUSINESS: BUSINESS LOCATION: MAILING ADDRESS: PHONE: BUSINESS gy cm/J(0.54 2 ►►►►►►******►►►►►►►►►►N►►►►N►H►►►►► i HOW MANY VEHICLE$ WILL BE AVAILABLE FOR YOUR OPERATION OR CONTROL ? LIST THE CATION O PROPOSED DEPOTS A,�N nT'E'R,MINALS. nnrtnPAs rib ('ne<r 'old �"�`� s a --P DEKC�RI$E E CQ�Oft SCHEME ft r 01 I I0A�TOI BE SED TO DESIGfYATEnYn VEHICLES. IS YOUR PR POSED RATE SCHEDULE-? • Tbne LIST THE HOURS BETWEEN WHICH YOU PROPOSE TO PROVIDE TAXIOAB SERVICE TO THE GENERAL PUBLIC, AND THE DAYS, IF ANY, ON WHICH YOU DO NOT PROPOSE TO PROVIDE TAXICAB SERVICE TO THE GENERAL PUBLIC. 5'�_n mak. /0 err p -n�/a ©* LIST THE NAMES AND ADDRESSES OF ALL OFFICERS AND STOCKHOLDERS OF THE COMPANY IF INCORPORATED. ,^ frt. DESCRIBE THE EXPERIENCE OF ALL OFFICERS AND STOCKHOLDERS IN THE TRANSPORTATION OF PASSENGERS. LIST THE FINANCIAL STATUS OF THE OFFICERS AND STOCKHOLDERS OF THE COMPANY, IF INCORPORATED, INCLUDING THE AMOUNT OF ALL UNPAID JUDGEMENTS AGAINST ANY OF THEM AND THE NATURE OF THE TRANSACTIONS OF ACTS GIVING RISE TO SAID JUDGEMENTS. TO WHOM SHOULD COMPLAINTS BE DIRECTED? APPLICANT, ON AN ATTACHED SHEET, PLEASE GIVE ANY FACTS WHICH YOU BELIEVE TEND TO PROVE THAT PUBLIC CONVENIENCE AND NECESSITY REQUIRE THE GRANTING OF A CERTIFICATE. i/, Ja rc2 v/— 75-00 T y��� C7 -as/ ,fiw e P 5 Taylor 0 Associates Insurance « Financial (Services Linda Phillips Auto, Home, Lite, Health, Commercial 203 Flolcomb P.O. box 866 SpunVPdalc. AR 72765 INSURED Office 479-751-4734 PAX 479-751-4648 Jack or Julie Johansen dba Party Time Ponies P.O. Box 367 Farmington, AR 72730 NSURAN ISSUE DATE (MM/DD/YY) 11-14-02 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. COMPANY A LETTER PI COMPANY B LETTER COMPANY LETTER COMPANY LETTER COMPANY E LETTER COMPANIES AFFORDING COVERAGE Nautilus Insurance Company • COVERAGES CO LTR X 1,I ' THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION DATE (MM/DD/YY) DATE (MM/DD/YY) LIMITS GENERAL LIABILITY XCOMMERCIAL GENERAL LIABILITY CLAIMS MADE OCCUR. OWNER'S & CONTRACTOR'S PROT. N0150258 NC184044 05-23-01 05-23-02 GENERAL AGGREGATE 05-23-02 05-23-03 PRODUCTS-COMP/OP AGG. PERSONAL & ADV. INJURY EACH OCCURRENCE FIRE DAMAGE (Any one Ilre) - MED EXPENSE IAM one person) $2,000,000 $included $1l000,000 $1,000,000 $ 50,000 $ 1/000 AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS GARAGE LIABILITY COMBINED SINGLE LIMIT BODILY INJURY (Per person) BODILY INJURY (Per occident) $ $ PROPERTY DAMAGE $ EXCESS LIABILITY UMBRELLA FORM OTHER THAN UMBRELLA FORM EACH OCCURRENCE $ AGGREGATE $ WORKER'S COMPENSATION AND EMPLOYERS' LIABILITY STATUTORY LIMITS EACH ACCIDENT DISEASE—POLICY LIMIT DISEASE—EACH EMPLOYEE $ $ $ OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/SPECIAL ITEMS Tethered Pony Rides "Llghts of the Ozarks Festival" CERTIFICATE HOLDER City of Fayetteville ACORD 25-S (7/90) CANCELLATION . i.. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL _.n DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES AUTHO IZED REPR SENTATIVE ©ACORD CORPORATION 1990 Northwest Equine Services 1650 N. Sunshine Road Fayetteville, AR, 72704-6340 (479) 521-5558 FAX: (479) 521-4650 Patient History Report For Julie Johanson — Jake From 10/282002 to 11/19/2002 Page 1of1 Account #: 1381 Owner.. Julie Johanson Address: 12395 W. Hwy 62 Farmington, AR 72730 Phone: (501)267-2101 Animal: Species: Breed: Color. Gender. Birthdate: Age. Weight: Jake Equine PONY BLACK Gelding 01/01/1993 9 years 10 months 22 days 0.00 Date Doctor Description Weight 11/18/2002 10282002 Paul Turchi Paul Turchi • R#17333; Rabies Vaccination EEE/WEE/I'ST Enceph. Vaccinati Oral Exam- Brief Acepromazine Injection 3m1 Clean Sheath 0 0 Northwest Equine Services 1650 N. Sunshine Road Fayetteville, AR 72704-6340 (479) 521-5558 FAX: (479) 521-4650 • • Patient History Report For Julie Johanson — Buttons From 10/28/2002 to 11/19/2002 Page 1of1 Account #: 1381 Owner. Julie Johanson Address: 12395 W. Hwy 62 Farmington, AR 72730 Phone: (501)267-2101 Animal: Species: Breed: Color. Gender Birthdate: Age: Weight: Buttons Equine PONY GRAY Gelding 01/01/1992 10 years 10 months 22 days 0.00 Date Doctor Description Weight 11/18/2002 Paul Turchi 10/28/2002 Paul Turcbi R#17331; Rabies Vaccination EEE/WEE/FET Enceph. Vaccinati Flush Naso -lacrimal Duct Oral Exam- Brief Clean Sheath Acepromazine Injection 3m1 0 0 • Northwest Equine Services 1650 N. Sunshine Road Fayetteville, AR 72704-6340 (479) 521-5558 FAX: (479) 5214650 Patient History Report For Juhe Johanson — Peanut From 10/28%2002 to 11/19/2002 Page 1of1 Account #: 1381 (Tuner. Julie Johanson Address: 12395 W. Hwy 62 Farmington, AR 72730 Phone: (501)267-2101 Animal: Species: Breed: Color. Gender. Birthdate: Age. Weight: Peanut Equine PONY PAUWHT Gelding 01/01/1995 7 years 10 months 22 days 0.00 Date Doctor Description Weight 11/18/2002 10282002 Paul Turchi Paul Turt:hi R#17341; Rabies Vaccination EEEIWEFJTET Enceph. Vaccinati Dormosedan 3ug Rompun Injection 1 ml Teeth Float & Examine Reversal; Qty: 0.5. Clean Sheath 0 0 Northwest Equine Services 1650 N. Sunshine Road Fayetteville, AR 72704-6340 (479) 521-5558 FAX: (479) 521-4650 • • Patient History Report For Julie Johanson — Bear From 10%28/2002 to 11/19/2002 Page 1of1 Account #: 1381 Owner. Julie Johanson Address: 12395 W. Hwy 62 Farmington, AR 72730 Phone: (501)267-2101 Animal: Species: Breed: Color. Gender. Birthdate: Age. Weight: Bear Equine PONY BAY Gelding 01/01/1984 18 years 10 months 24 days 0.00 Date Doctor Description Weight 11/18/2002 10/28/2002 Paul Turchi Paul Turchi R#17335; Rabies Vaccination EEE/WEE/TET Enceph. Vaccinati Oral Exam- Brief Clean Sheath Acepromazine Injection 3m1 0 0 Northwest Equine Services 1650 N. Sunshine Road Fayetteville, AR 72704-6340 (479) 521-5558 FAX: (479) 521-4650 Patient History Report For Julie Johanson — Alex From 10/28/2002 to 11/19/2002 Page 1 of 1 Account#: 1381 Owner. Julie Johanson Address: 12395 W. Hwy 62 Farmington, AR 72730 Phone: (501)267-2101 Animal: Species: Breed: Color. Gender. Birthdate: Age: Weight: Alex Equine PONY SORREL Gelding 01/01/1992 10 years 10 months 22 days 0.00 Date Doctor Description Weight 11/18/2002 10282002 Paul Tumhi Paul Turchi R#17339; Rabies Vaccination EEE/WEE/TET Enceph Vaccinati Oral Exam- Brief Clean Sheath Acepromazine Injection 3m1 0 0 Northwest Equine Services 1650 N. Sunshine Road Fayetteville, AR 72704-6340 (479) 521-5558 FAX: (479) 521-4650 • Patient History Report ForJulieJohanson — Spur From 11/18/2002 to 11/19/2002 Page 1of1 Account#: 1381 Owner. Julie Johanson Address: 12395 W. Hwy 62 Farmington, AR 72730 Phone: (501)267-2101 Animal: Species: Breed: Color. Gender. Birthdate: Age. Weight: Spur Equine Welsh Pony SORREL Gelding 01/01/1974 28 years 10 months 26 days 0.00 Date Doctor Description Weight 11/18/2002 Paul Turchi EEFJWEE/I'ET Enceph. Vaccinati R#17337; Rabies Vaccination Exam Health Certificate 0 See reverse for more OMB information rvrtni rrrnv vtu - LMB NUMBER 0579 -0127 • US. DEPARTMENT OFAORICULTU ANIMAL AND PLANT HEALTH INSPECTIO CE EQUINE INFECTIOUS ANEMIA LABO ORY TEST - (VS Memorandum 555:8) SERIAL NO. B .1859807 CESSION NUMBER 7-46,),0.1?// 2. DATE BLOOD D WN 3 3()..,3()..,orme F Withnuf Ar4nn,.�s.� n,.�..::L�:___ ria rte_ .,___ First Test Export 7.NAME AND ADDRESS OR STABLE/MARKET (Please print or type) i y g 4� Complete Addresses Including Zip Codes, Counties, and Telephone .............. 3. REASON FOR TESTING 9 Market ■ - Change of Ownership Show Retest ❑ El First Test Export 7.NAME AND ADDRESS OR STABLE/MARKET (Please print or type) i y g 4� 4. GEOGRAPHIC INFORMATION SYSTEMS MIS) lddn lvvvv) 5. VETERINARY LICENSE OR ACCREDITATION 6. TEST TYPE / 7 A //////yyy��, .t .' J !Y rgw 601 ACID , Mei {� •ird Zip Code %.x. s Or ELISA Tel No. /.. '2)9 Ea County ) 4'S 1 8. NAME AND ADDRESS • OWNER (Please pain' type) �. / 9. E AND • . DRESS OF V TE IINAARI • • (Please , °° r CV /t Na print type) JO ;.-m, Ur it_ -t -` -•Isa/ sa r i) /may r-1 � .f mn/ Zip Code7 /A • a Zip Code N Court Tel No. JCI - I - 1 L h' /'• " • IW O Tel No. County CERTIFICATION OF FEDERALLY ACCREDITEDVETERINARIAN I certify the specimen submitted with this Form was drawn by me from the horse described below on the date indicated above. 10. SIGNATURE FEDERAL CREDIT D R .18a. i 11. TYPE OR PRINT SIGNAT ' NAME 2. SIGNATURE DATE ERTIFICATION OF OWNER OR OWNER'S AGENT / I certify that I have examined this form and, to the best of my knowledge and belief, this form is true, correct and complete. 13.51 ATUREOFOWNERWNER'S AGENT 16. Tube No. 17. Official Tao No. 11J TYPE OR PRINT SIGNATUR E 18. Tattoo/Brand Vier 19. Name of Hone .C/ A/W I i' 21. 1 . 42_ i r_l 20. Broad Electronic I.D. No. Color SHOW ALL SIGNIFICANT MARKINGS, WHORLS. BRANDS. AND SCARS 4\ /3 15. IGNATURE DATE M•Male Age or F • Female 23. AO DOB /1 24. Sex N - Neuter 1 - Coronet, 2 - Pastem, 3 - Fetlock, 4 - Knee, 5 - Hock 5. HEAD /4Fr4/ /rt1ul� 7 LEFTFORELIM 1. LEFT HINDUMS NARRATIVE DESCRIPTION AND REMARKS 26. OTHER MARKS AND BRANDS 28. RIGHT FORELIMB 30. RIGHT HINDLIMB LABOR4 Ry.NAME/OIN/S I /:a �V FOR LABORATORY USE ONLY 2. ¢ATE RECEIVED 33. DATE REPORTED OUT ar,� oa �J'/y 36. SIGNATURE OF TECHNICIAN 'alslflcation of this form or knowingly using a falsified a r mal o se and may result in a fine of not more than $10,000 or Imprisonment for not more than years or b.• h (U.S.C. Section 1001). 34. TEST RESULTS B-N€bative ❑ Positive ❑ AGID ,�.6tISq 35 REMARKS FORM 10-11 (MAY 2000) (Replaces the VS 10-11 (4-90) and VS 10-11T (10-97), which may be used.) PART. 3 -OWNER win" vim, ,,,w Iduun U.S. DEPARTMENT OF AGRICULTURE I SERIAL NO. ANIMAL AND PLANT INSPECTION INFECTIOUSANEMIA ABOE u'RY TEST (VS Memorandum 555.8) FORM APPROVED - OMB NUMBER 0579 - 0127 B 1859808 1 CESSION NUMBER 2. DATE BLOOD Dr WN 011~ a • . Forms Without Adequate Descriptions Of The Horse and Complete Addresses Including Zip Codes, Coun ies, and Telephone Numbers Will Not Be Processed. 3. REASON FOR TESTING 0 Market ❑ Change of Ownership 4. GEOGRAPHIC INFORMATION SYSTEMS IGISI fddrmNWwl ❑ Show ❑ First Test Retest ❑ Export 5. VETERIN Y LICENSE OR , Ra ITATION Nq. Itf�4/ 7. NAME AND ADDRESS OR STABLE/MARKET (Please pont or type) 6. TEST TYPE ❑ AGID ' be/ v an - i "' _.' _ i ZIp Code 7 c� i LISA Tel No. ,l E AND A• •RESS OF • NERfPlease pont or type) 9 AME 1 D •1a ���IS• /y/DRESS eF ET IT ARIAN (Please pont or type) 1' 1/ is IIT ma sl • ' ' 1(_ rr�-, r 2:k-_ w y/.,, A n. � a /.i' li'7_I<ra. �'L Zip Code Te No. - —� - AICtralnalEirniaNtea CERTIFICATION OF FEDERALLY ACCREDITED VETERINARIAN I certify the specimen submitted with this Form was drawn by me from the horse described below on the date indicated above. 10. SIGNATURFOF FEDE pEDICHA�Ate��j�/ 11. TYPE OR PRINT SIGNATURE NAM ljyJ -,IC ' . _! J (/ . I ' 1 /J r , t_. A P �//(kr�/ 12. SIGNATURE DATE aC/L/- CERTIFICATION OF OWNER OR OWNER'S NER'S AGENT . - 1 f� L�/ I c�—J G1�c O I certify that I have examined this form and, to the best of my knowledge and belief, this form is true, correct and complete. 13. SIGNATURE OF OWNER OR OWNER'S AGENT yy 14 TYPE OR PRINT SIGNATURE{1AME 15. SIGNATURE DATE ei rub* ORkUI 20. 21. 22. 23. ^ M•MaN ) CrID gall() Tao No. Dolor Bread EIecWNc AQeor 24. I.D. No. 008 Sea F • Female /() 1444//1 � l {sss :Gelding 10 SHOW ALL SIGNIFICANT MARKINGS. WHORLS, BRANDS,AND SCARS r ---ii vv r - sr -A-• _ TattoolBrand 19, Name o/ Horse 36f itoA/ S 1 - Coronet, 2 - Pastem. 3 - Fetlock, 4 - Knee 5 - Hock HEAD NARRATIVE DESCRIPTION AND REMARKS LEFT FORELIMB LEFT HINDLIMB 26. OTHER MARKS AND BRANDS 26. RIGHT FORELIMB 30. RIGHT HINDLIMB diABORATORY NAMEJCITYIST TE -bum-l-4,i i%�4.4 FOR LABORATORY USE ONLY CiOnifffr alsifcation 32. DTE RECEIVED 33. DATE REPORTED OUT O 36. SIGNATURE OF TECHNICIAN stin Aci FORM 10-11 this form or knowingly using a falsified f•rm for not more than 5 (MAY 2000) (Replaces the VS 10-11 (4-90) and VS 34. TEST RESULTS .e -Negative 0 Positive 35. REMARKS ❑ AGID ].ELISA al offense d ma • fluff in a fine of not more than 510,000 or Imprisonment years or both ( .S.C. Section 1001). 10-11T (10.97), which may be used.) PART. 3 -OWNER See reverse for more OMB information. . v .....v ...vvw VIYIp,VV1VIOCR V3IU-UILI U.S. DEPARTMENT OF AGRICULTU ANIMAL AND PLANT HEALTH INSPECTIO CE EQUINE INFECTIOUS Memorand7um 555B0 ORY TEST SERIAL NO. B1859809 CESSION NUMBER 2. DATE BLOOD DRAWN 3.3 02- / � _ �y�/ • Change of Ownership Vi Retest • escr Iptions Of The Horse and Complete Addresses Including Zip Codes, Counties, and Telephone Numbers Will Not Be Processed CERTIFICATION OF FEDERALLY ACCREDITED VETERINARIAN I certify the specimen submitted with this Farm was drawn by me from the horse described below on the date indicated above. 10. SIGNATURE OF FEDERA ACCR n .D V ERIN: '.: 11. TYPE OR PRINT SIGNATURE NAME j 12. SIGNATURE DATE / �� /// 7 1 , CERTIFICATION OF OWNER OR OWLNER'S AGENT'` �' I certify that I have examined this form and, to the best of my knowletlge and belief thio fora, it m.d D..o.•r 3. REASON FOR TESTING ❑ Show • First Test 7. NAME AND ADDRE OR STABLE/MARKET 4e14. C. / r (Please print or type) 0 Markel • Change of Ownership Vi Retest • Export 1. GEOGRAPHIC INFORMATION (GIS) (ddnnfw) S. VETERINARY UCENSE OR ACCREDITATION NO. CCEDI AnONNO. 6. TEST • 9-fCISA TYPE AGID l7i,4::SYSTEMS I4l" /4 ,6- Zlp Code 5 .2_.)dVpT 7, 7 el o. County 8. N E AND ADDS OF OW R (Please pont or type) Ol2fi iM16- foi✓/ts 9 AME AND ADORES OF yETERINARIAN (Please pont or type) t u� l r� p�3ixv r 22. Electronic I.D. No. D Pa , ��'7�13��1�',Low 6y 1 . Zip Code 742 73D / M•Male F •Female A 4.egT7 1/Y` G y (� Zip Code J 13 0 Tel o. �! ,1(0 / 3�1.' J County T o. I Li -1 .2 &35 County I AJ S)..,, AM _ G.G. N• Neuter I'1 CERTIFICATION OF FEDERALLY ACCREDITED VETERINARIAN I certify the specimen submitted with this Farm was drawn by me from the horse described below on the date indicated above. 10. SIGNATURE OF FEDERA ACCR n .D V ERIN: '.: 11. TYPE OR PRINT SIGNATURE NAME j 12. SIGNATURE DATE / �� /// 7 1 , CERTIFICATION OF OWNER OR OWLNER'S AGENT'` �' I certify that I have examined this form and, to the best of my knowletlge and belief thio fora, it m.d D..o.•r . WHORLS, BRA DS, AND SCARS 1 - Coronet, 2 - Pastem, 3 - Fetlock, 4 - Knee, 5 - Hock NARRATIVE DESCRIPTION AND REMARKS t5 HEAD 26. OTHER MARKS AND BRANDS T. LEFT FORELIMB 28. RIGHT FOREUMB :9. LEFT HINDUMB 30. RIGHT HINDUMB 1. ORATORT LAME/CrTYISTA7 41 ;� At. FOR LABORATORY USE ONLY 3ATE RECEIVED 22. 449 23oz 33. DATE REPORTED OUT 31 TEST RESULTS 36. SIGNATURE OF TECHNICIAN C2 Negative Q Positive ❑ AGID ELISA !T 135. REMARKS Falsification of this form or knowingly using a falsified fors a'criminaKOffe se and ay res 1i:fine of not more than 510,000 or Imprisonment for not more than 5 years or both (U.S.C. Section 1001). S FORM 10-11 (MAY 2000) (Replaces the VS 10-11 (4-90) and VS 10-11T (10-97), which may be used.) PART. 3 -OWNER w p e. 13. SIGNATURE `' OF OWNER OR OWNER'S AGENT 11. TYPE OR PRINT SIGNATURE n L nf,; p NAME RAi r):1 nil 15„„..SIGNATURE DATE 2302-- 16. Tube No /TVA 17. Official Tao No. 16' Tattoo/Brand 19, Name of Hone 20. Color 21. Breed r 22. Electronic I.D. No. Age DOB 3' or 21. Sax M•Male F •Female 1 S �� Z f ^� ') �'v�/ _ G.G. N• Neuter a cunur Al 1 o,nu,e-,e.a.,e .. a ..,.,.,..'Cir . WHORLS, BRA DS, AND SCARS 1 - Coronet, 2 - Pastem, 3 - Fetlock, 4 - Knee, 5 - Hock NARRATIVE DESCRIPTION AND REMARKS t5 HEAD 26. OTHER MARKS AND BRANDS T. LEFT FORELIMB 28. RIGHT FOREUMB :9. LEFT HINDUMB 30. RIGHT HINDUMB 1. ORATORT LAME/CrTYISTA7 41 ;� At. FOR LABORATORY USE ONLY 3ATE RECEIVED 22. 449 23oz 33. DATE REPORTED OUT 31 TEST RESULTS 36. SIGNATURE OF TECHNICIAN C2 Negative Q Positive ❑ AGID ELISA !T 135. REMARKS Falsification of this form or knowingly using a falsified fors a'criminaKOffe se and ay res 1i:fine of not more than 510,000 or Imprisonment for not more than 5 years or both (U.S.C. Section 1001). S FORM 10-11 (MAY 2000) (Replaces the VS 10-11 (4-90) and VS 10-11T (10-97), which may be used.) PART. 3 -OWNER