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Item C02 C.2 � � �, BOARD OF COUNTY COMMISSIONERS County of Monroe � ��r�i �r � s�� Mayor Heather Carruthers,District 3 The Florida.Keys � � � ������]�j Mayor Pro Tem Michelle Coldiron,District 2 Craig Cates,District 1 ^_, David Rice,District 4 Sylvia J.Murphy,District 5 County Commission Meeting August 19, 2020 Agenda Item Number: C.2 Agenda Item Summary #7115 BULK ITEM: Yes DEPARTMENT: Emergency Services TIME APPROXIMATE: STAFF CONTACT: James Callahan (305) 289-6088 N/A AGENDA ITEM WORDING: Approval for issuance (renewal) of a Class A Certificate of Public Convenience and Necessity (COPCN) to Florida Keys Ambulance Service, Inc. (FKAS) for the operation of an ALS transport ambulance service; specifically for inter-facility transports for the period September 22, 2020 to September 21, 2022. ITEM BACKGROUND: In August 2018, a Class A COPCN was issued to FKAS to operate an ALS transport ambulance service (specifically inter-facility). FKAS' certificate will be expiring on September 21, 2020. In view of the foregoing, FKAS is applying to renew this COPCN which would become effective September 22, 2020 and end on September 21, 2022. PREVIOUS RELEVANT BOCC ACTION: On September 21, 2016, Item C.26, the MCBOCC approved the issuance of a Class A COPCN to FKAS for the operation of an ALS transport ambulance service (specifically inter-facility) for the period September 22, 2016 to September 21, 2018. On August 15, 2018, Item C.16, the MCBOCC approved the issuance (renewal) of a Class A COPCN to FKAS for the operation of an ALS transport ambulance service (specifically inter-facility) for the period September 22, 2018 to September 21, 2020. CONTRACT/AGREEMENT CHANGES: N/A STAFF RECOMMENDATION: Approval DOCUMENTATION: Florida Keys Ambulance Class A Application FL Keys Ambulance Service, Inc. - Renewal of COPCN Class A Certificate Packet Pg. 129 C.2 FL Keys Ambulance - Class A COPCN Final FINANCIAL IMPACT: Effective Date: 09/22/20 Expiration Date: 09/21/22 Total Dollar Value of Contract: N/A Total Cost to County: N/A Current Year Portion: N/A Budgeted: N/A Source of Funds: N/A CPI: N/A Indirect Costs: N/A Estimated Ongoing Costs Not Included in above dollar amounts: N/A Revenue Producing: N/A If yes, amount: N/A Grant: N/A County Match: N/A Insurance Required: Yes Additional Details: N/A REVIEWED BY: James Callahan Completed 08/01/2020 2:48 PM Pedro Mercado Completed 08/01/2020 2:51 PM Purchasing Completed 08/03/2020 8:05 AM Budget and Finance Completed 08/03/2020 8:08 AM Maria Slavik Completed 08/03/2020 8:12 AM Abra Campo Skipped 08/03/2020 10:44 AM Kathy Peters Completed 08/03/2020 10:45 AM Board of County Commissioners Pending 08/19/2020 9:00 AM Packet Pg. 130 C.2.a BOARD OF COUNTY"COMMISSIONERS County of MonroeMayor Sylvia J.Murphy,District 5 FloridaThe ey Mayor Pro Tern Danny L.Kolhage,District 1 Michelle Coldiron,District 2 Heather Carruthers,District 3 Iro" David Rice.District 4 Division of Emergency Services „ Fire Rescue Department 490 63,d Street,Ocean Marathon,FL 33050 Phone: 305-289-6004 _ Fax: 305-289-6336COPCN , u CJ Classheck List Please Attach all of the following documents when submitting your application: y LTe name, business mailing address, and telephone number of the service. The name, age, address and telephone number of each owner of the emergency medical service,or, if the service is a corporation,the directors of the corporation and of each stockholder of the corporation, or, if the service is a volunteer organization,the officers of the organization. i The date of incorporation or formation of the business association. o The level of care to be provided,specifying BLS or ALS, and if ALS,then specifying whether service is to include transport or nontransport capabilities. C4 The zones that the service desires to serve. 6� The applicant's present and proposed base station and all substations. y l The names of all emergency medical technicians, paramedics and drivers to be utilized by the applicant® the roster will include the state certification number,date of certification expiration, and any other relevant training of said personnel. fu/ The year, model,type,department of health ambulance permit number, mileage and state vehicle license number of every ambulance vehicle used by the applicant. G A description of the applicant's communication systems, including its assigned frequency, call numbers, mobiles, portables,other frequencies in use,and a copy of all FCC licenses held by the applicant. The names and addresses of three U.S. citizens who will act as references for the applicant. C A schedule of rates which the company will charge during the certificate period. C / Verification of adequate insurance coverage, during the certificate period. An affidavit signed by the applicant or an authorized representative stating that all the information contained in the application,to the best of the applicant's knowledge, is true and correct. r, A copy of the applicant's contract with a medical director. A copy of all standing orders as issued by the medical director. ❑ Such other pertinent information as the administrator may request. An initial nonrefundable application fee of$50.00/ 25.00 enewal Packet Pg. 131 MONROE COUNTY, FLORIDA APPLICATION FOR CERTIFICATE OF PUBLIC CONVENIENCE AND NECESSITY (COPCN) CLASS A EMERGENCY MEDICAL SERVICE (PRINT OR TYPE) ❑ INITIAL APPLICATION-S50.00 ® RENEWAL APPLICATION-S25.00 IF RENEWAL,PLEASE LIST NUMBER OF PREVIOUS CERTIFICATE:# 18 - 04 A 1. NAME OF SERVICE FLORIDA KEYS AMBULANCE SERVICE, INC. BUSINESS MAILING ADDRESS P.O. BOX 1259 TAVERNIER, FL. 33070 BUSINESS PHONE NUMBER 305-414-8136 EMERGENCY PHONE NUMBER 305-975-4387 2. TYPE OF OWNERSHIP(i.e.,Sole Proprietor,Partnership,Corporation,etc.) S CORPORATION z U CL DATE OF INCORPORATION OR FORMATION OF THE BUSINESS ASSOCIATION AUGUST 6, 2012 CJ 3. LIST ALL OFFICERS,DIRECTORS,AND SHAREHOLDERS(Use separate sheet if necessary): y NAME AGE ADDRESS TELEPHONE# POSITION/TITLE EDWARD F BONILLA 52 917 RED BIRD RD 786-203-6576 CEO / OPS MANAGE C c m 4. LEVEL OF CARE TO BE PROVIDED: ❑ BLS or®ALS IF ALS: ®TRANSPORT or❑NON TRANSPORT 5. DESCRIBE THE ZONES(S)THAT YOUR SERVICE DESIRES TO SERVE (Use separate sheet if necessary): m Inter-facility transports in all geographical locations of Monroe County, Florida. 6. LIST THE ADDRESS AND/OR DESCRIBE THE LOCATION OF YOUR BASE STATION AND ALL SUB- STATIONS (Use separate sheet if necessary): BASE STATION 91421 OVERSEAS HIGHWAY SUITE #102. Tavernier, FL. 33070 SUB-STATION 2 : 11399 OVERSEAS HIGHWAY#1, MARATHON, FL. 33050 SUB-STATION 3 : 21460 OVERSEAS HIGHWAY. UNIT 1, CUDJOE KEY, FL. 33042 Page 1 of 6 Packet Pg. 132 C.2.a 7. IMF C"RUIL;VOUR COMMUNICATION NIC; T'ION SYSTEM(Attach copy ofall FCC licenses): FR1,',QL1JE,Ncl Ir"'S CALL N U NIBERS #OF MOBILES #Of," PORTABLES MONROE COUNTY 305-41 -313 7 e ........... ...... �_...,w..m. �..._,�.... � � . L<I T T F NAMES AND r4DDRESSL OF 11-i ( U.S.(ATIZLNS WHO WILL ACTAS REFERENCESFOR YOUR SERVICE. ADDRESS I I, THOMAS STEED 91500 OVERSEAS HIGHWAY, TAVERNIER, FL. 33070 JAMES FAKTOR ! 13720 29 . EDGARD MIRANDA � 05 Sod. 27 I . HOMESTEAD, L, 33035 gar ATTACH A SCHEDULE OF RATE WIIIC:°II YOU E'RV'IC':"I ILL(AI. I CIF IIURINC TIFF COPC"N PERIOD. tJ 11 PROVIDE A R,Irid-'ATION OF DEQ11- TE INSURANCE, COVERAGE DURING THE C:OPCN PERIOD. 11, ATTACH eV COPY OF YOUR SERVICE-SCONTRACTWITH A MLDICAL DIRECTOR. TOR. c 12. ATTACH A COPY OF fVLeL,;T,°aN DIN(x ORDERS AS ISSUED BY VOUR MEDICAL DIRECTOR. 13. ATTACH A CHECK OR NICINEV CIIZIIER IN T'IIF All PROPR IATF ,VMO NT,MADE P VABLE TO THE ONROEi COUNTYBOARD OF C'C:UN'T 'CO'MMISSIC NI RS. f y I,THE `? I L11 IGNED REPRESLN'TATIYF;OF THE ABOVE NAMED SERVICE, O IILICFI3V ATTEST EST MY SERVICE � MEETS ALL OF`I E REQUIREMENTS EME:NT FOR OPERATION OF AN E;"+ E RGENC Y ;NIEDICAL URN"IC".E,IN SOON F � C`Ot'NI-Y iND"I°IIFE T' 7°F.CIF FI-,C:lRIDA. I hLs 'I`I-IE AI"I"IE; T'TtiAl°r1LL T° F I"'IFCI �I "rI N CONTAINED IN E THIS PPI_,IC" TION,TC E s,r o ' NIIV Lt.� C-,F;,IS TRUE.RNLI CORRECT. � c Ay Y Pu T ynsaa NCI"E"AR SEAL �, � i s Il ,aa2o � a� NCB I ARN'SICNAT I, DA l E Pace 6 Packet Pg. 133 C.2.a 6 PERSONNEL—PARAMEDICS NAME PARAMEDIC CERTIFICATION First,Middle,Last SOCIAL SECURITY# CERTIFICATION# EXPIRATION DATE EDWARD F BONILLA515681 DEC. 1, 2020 EDGARD MIRANDA PMD 206162 DEC. 1, 2020 YERANI LABRADA PMD 514322 DEC. 1, 2020 JAES W FAKTOR PMD 514804DEC. 1, 2020 CL a- c Page 3 of 6 Packet Pg. 134 C.2.a PERSONNEL--EMERGENCY MEDICALTECHNICIANS NAME E C CERTIFICATION First, Middle,Last 0CIA , LC"IIICI T)`# ('EXTIFICATION# I. III II-A I:IO D '.I.E DEV�N GENCHI n.v. . w. EMT 55 027 DEC $ 2020 ANTHONY ro. a«.a . _ EMT 555944 DEC, 1 , 02 _._. r. . _. _... CL _...a e W 1 mo...«..«....�._....m. ....�,..«_.m.m..,» .,« .,�.�,.«. ..,,..... ate.... _____._._.......m.®....�.w....,,..,«.,-- .._....gym. --_,...^.--.... m..v ........inn.,_„, - ..b,..........«. .........,.... ..«ve�....®..._..�.m,_..v,.,,„.,...,,.�..,.a.,...,.. »..,„„, t » .an " Packet Pg. 135 C.2.a Fitt �e6D,La�ta D�'6,4D `„f '�d.1 G3 11. 01111114�Yll k���IVE l.�t.�..��k.# O ISSUAN � 1'. 1'I �.Y"IQ�a 6�,�,I � 09 09CL 124_ 2C a - r0 FL 1 09/09/2024 .w _.. ......_—...._..... ..m.._..,_....., ______...,........_. _. _...,.__.. ..,..... _...� r _E j 7 ... 3 fn _...,..,..,.. ....... .,...._...__... ._..m.,_.e.._..._,.._. -... wow _._.. _ _....._..........__........ ___ _:_ __ ._._ __ ........ I DO RIE E Y ATITST,°D O TRIE BES D°OF MY KNO%r IAID ITS THAT ALL OF,rHE ADDDIVr::NAMED DRV ERS DO MEET A r D F THE Rl.D r 1141"MEN,I CHAPTER 401.281 F.S,AND E`D,D.I'I'E 64E.2.012 FAC FOR A`4rR1`L,DN4"E DRIVERS. SE U- 5-1 �. y Vie. %'=APJTA YALA Packet Pg. 136 C.2.a VEHICLES Vor$'mch Affibulance 0 wntol Bv lour [.rwica, a6-If fflfts».THIS SPECIFY ¢ CRI A.�d GE' ANSI fit_ #"�,t�'�tr�tttt�^'R Pt., N(t`t° ,fit »aaBt., Ll N'I11,hl4,SP F II � 8 ���t�ti�����, �< t"§Ci fk �Y13�&taL �'t?� t� MI CL APE III BC3000a 2017 76 7,00 1 C� 6Fi11 6107 650 206 L TRANSPORT T 6It! 3000 2017 5 O�IG 3 R °IH122746 C�J Fi20 210 3 L I�TR N� al2" ^.... ._. g ---------- .......... ............ E ' � 3 a i (..............v..,.....m....................�._..._._..._.'..,,,.,..._.,...__............ _..._..e�...,.__d .__._.__..._ .._.v_..m.m,._..m- ....__,.........»,w.._.._.._ __..._..,..�....�.__..____. ......m,....E.,,».._.... —._._..®....._...,, _..—......_,......... Packet Pg. 137 C.2.a ItoFloridaeAmbulance Service, Inc. P.O. Box 1259 Tavernier, . 33070 Ph.: 786.203.6576-Fax: 305.396.5889—Email: Flakeysambulance@aoi.com CD CLASS A COPCN APPLICATION ITEM 9: SCHEDULE OF RATES CL Transport Base Fee — Basic Life Support (BLS) $750.00 Transport Base Fee — Advanced Life Support (ALS 1) $850.00 Transport Base Fee — Advanced Life Support ( S2) $950.00 Transport Base Fee - Special Care Transports (SCT) $19200.00 Mileage Charge - Loaded mile $13.00 These rates include all medically necessary supplies, equipment, and medications used during the transport. y i2 Packet Pg. 138 4 C.2.a ----1 FLO K Y- 1 4C CLLE Ct�►R® I DATE, D , CERTIFICATE OF LIABILITY INSURANCE ..1L...__._1116/2020_ THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED Y THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER, IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement, A statement on this certificate does not confer rights t0 the certificate holder in lieu of such endorsernent�sj. PRODUCER - i CONTACT ;JAG Insurance Grou ,LLC I PHONE ..._.. rA =999 Ponce De Leon lard9(err ampEI ( 06)842-3600 __.._ tic aaas 06)642 60 Suite 600 !Coral Gables,FL 33134 _......._.._..._ __.____...�,.__..� INSURER A:National Interstate-In ranc Cow__.__ .-__.._.__....._.._. .___v.._..._.._._........_.._.._........_..................................___........._..._.... ...._..._._..__...._.._.__..__._._ .. ..t.._ _...___._..__. INSURE® I INSURER !.~..__....._. _ Florida Keys Ambulance,Inc, INEERERc. -..... ___�._.... ._.._.__... i 91421 Overseas Highway .INSURER,D Tavernier,FL 33070 -- .-__._.____.._. __..__....__._.._.___ _........... _.. _...__._. -------------.... _......_._......__..__. ._. INSURER F COVERAGES CERTIFICATE NUMBER. REVISION NUMBER: THIS®IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE.INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOT THSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CON-I-RACT OR OTHER DOCUMENT PATH RESPECT TO WHICH THIS In 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 SHOWNMAY HAVE BEEN REDUCER BY PAID CLAIMS.. _.......... ___ __ fJ —.._;INSR ._____ ..~......_._._..i.AT6i3l,..51& -_. ~�P&JLIC�'-EFF PRE !E�YEXP .�._.. RE OF INSURANCE POLICY NUMBER p, ky .d y. . LII'A �T ..._...._ � '._....i' .s,,...�. A I X (COMMERCIAL GENERAL LABILITY LA6,4i c?: U°��N�., ._....1,400 00C _ _.. I cLAIM,,-MALE "CUR tLJG 0000161-81 7/16/2020 7116/2021DaMA E� O RENTED 100__O_OC ( L! a✓ c, € all T._.. U 1,000,00( 0 O __.._. _ ` GEM-ACatzRa,..�'.AYT L!MIT APPLIES PER � uLtV �L� v L -FT[ � 3,000,00 M f X POLICY J'o ` D L � [ I � ' � � ----- 00C a ,E�, E 5 E{iL7E '!'-S-"cr6 ;--w'R{ S'r Q, TSI.xa. f AUTOMOBILE LIABILITY ��...._..._._ � rOME..,,INED iGLE LIN,IF m..�..._ 1,000,00C f p ANY AUTO ; �AAL 00001 8-01 7/1 /2020 € 7/16/2021 130.—DIL I, . � y,��r ,w� _._ __ In _...__. C}AINECI I ( .atTIiEGIULEC} € . AUTOS ONLY (�t ALIT OS I ( !E3f',L tE Till Hff t N( C I PROPERTY DAMAGE (� ...._. AU US ONL t AU C� �hE.Y I UMBRELLA LlAB --'.f,tlt.}£''a f E:,C.k Uf'C"UO�edE?vc;c _..._ E EXCESS LIAB I CI AIMS-MADE A.GGREGA. E:... ... ._._~„__' .......... ..... ...._REIFENT€ON t _ WORKERS COMPENSATION AND EMPLOYERS LIASILQTY YIN In [F,.. $ € ANY �anCda re�ryirr I.sCtM M EXCLUDE N s A; F..i.�.DI SEA, EAS EAEMPLOYE-.: >s ce rEba under ....._ ...____~____... ... t8 ! rk L'i'E'l,Y.iyC3F t'?PEP.a3 CDI'df:b i.vL............. .. _d......._ _ £ _ ,,;®t_CJ„-„SFsa.L r'C.f 6!"Y,l,; iIT_,,. .............a.w. A Professional Lia ill I,.PL 0 00137-01 7/161 020 711612021 (Each Clairrl 1,000,OOi '0 A Trfessional L"aabill ILPL 0000137-01 7/1662020 7/16/2021 Aggregate 3,000,00( rL DESCRIPTION OF OPERATIONS 6 LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached It more space is required) Gc7 C U �,....._.._......__._.~...____ _.........._. ...............................____�_..._. ..,._._______...._..... .....______..~...... _..._.__..._. CERTIFICATE HOLDER _._ �. CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, Monroe County Fire Rescue ACCORDANCE WITH THE POLICY PROVISIONSCE WILL BE DELIVERED IN 490 63rd Street Marathon,FL 33050 - ---- - AUTHORIZED REPRESENTATIVE.�. g C t' n � l , L..____.___ I A. m.. ®.. .. __.._. _- _------...— ACCORD 25(201 /0 ) 0 1 956-201 5 ACORD CORPORATION. Ali rights reserved. The ACORD name and logo are registered marks Of ACORD Packet Pg. 139 C.2.a Service,Florida Keys Ambulance Inc. o P.O. Box 1259 Tavernier, L. r 33070 t Ph.: 786.203.6576- Fax: 305.396.5889—Email: Flakeysambulance@aol.com This agreement dated July 15, 2020 by and between Florida Keys Ambulance Service, Inc herein referred to as the Ambulance Service, and Dr. Thomas Steed, Physician, herein referred to as the Medical Director. The purpose of this agreement is to provide the Ambulance Service with a medical director to enable them to provide Basic, or Advanced life support to the community they serve. This relationship may be terminated by written notice served upon the Medical Director at least seven business days prior to the effective date of said termination. The Medical Director may suspend or U CL terminate the relationship at will for cause, as defined hereinafter, or upon seven business day notice without cause. U The Medical Director agrees to: 1. Meet regularly with Ambulance Service and providers at least once per quarter or as often as U necessary. 2. Be Medical Director of record for the Ambulance Service as required and Pursuant to Florida Statute Chapter 401, and Florida Administrative Code 64J-1.004, and will perform all duties associated therewith. . Be available to Ambulance service officers when needed to advise on EMS issues. . Provide oversight to the agency's pre-hospital quality assurance/quality improvement program. The Ambulance Service Agrees to: 1. Be responsible for the transmission of all communications from the Medical Director to all y Ambulance Service providers. 2. Take necessary steps to ensure participation by its providers in all programs and courses required by the Medical Director including but not limited to protocol requirements, continuing Medical Education and Quality improvement. . Monitor the activities of each provider and keep accurate records, which shall be made available to the Medical Director or designee upon request. An officer shall be appointed to y maintain such records. . Forward immediately to the Medical director any and all complaints, notifications, summonses, subpoenas, letters and communication of any nature received which in any way bears on the quality of service rendered, is suggestive of any possible lawsuit or legal proceeding or in any 0 ways bears on the competence of any ambulance service provider. 5. Abide by and strictly adhere to all standards and protocols and other requirements by the Medical Director and agrees to suspend any ALS medical privileges for any "provider" for failure to comply with this provision. Signed: I MEDICAL I ECT DATE AjrX_NC_ENkR ICEANAGE /CEO DATE Packet Pg. 140 C.2.a Floridas Ambulance Service, Inc. Box 1259 Tavernier, . 33070 Ph.: 786.203.6576-Fax: 305.396.5889—Email: Flakeysambulance@aol.com APPLICATION ITEM 12 : PROTOCOLS W CJ CL Dear Commissioners: This letter certifies that I, Dr. Thomas M. Steed, acting as Medical director for Florida Keys Ambulance Service, Inc. approves the Florida Regional Medical protocols to be used by Florida Keys Ambulance Service, Inc. as standing orders for interfacility transports and also that at this time there are no changes to these protocols. Truly yours, DR. Thomas M Ste d, MD. DATE MEDICAL DIRECTOR c 1 -4 — 9C E�lward F. Bonilla DATE OPSMANAGER/CEO Florida Keys Ambulance Service, Inc. Packet Pg. 141 C.2.a BOA F COUNTY COMMISSIONERS k-.ounty of MonroeMayor Heather Carruthers,District 3 e Florida Keys Mayor Pro Tern Michelle Coldiron,District 2 � Craig Cates,District 1 David Rice,District 4 Sylvia J. Murphy,District 5 Monroe County Fire Rescue 490 63r1 Street Ocean Marathon,FL 33050 Phone(305)289-6088 MEMORANDUM CJ CL CJ Nicole FCaitlin rs -- c Checkfor Deposit 07/20/2020 Attached please find Check#1010 dated 07/1 /2020, in the amount of$25.00, to be deposited in the General Fund. This check has been issued for the renewal application of a Class A Certificate of Public Convenience and Necessity for Florida Keys Ambulance. Thank you, c— Caitlin Bourassa Packet Pg. 142 (fl a) NDdOD V ss l ) uoge3ilddV V sselo 93uelnqwVs! lala 1 :4u9ua o 44 co a d aC U ' tC a -- 1`i i 7 GO djli c ZO ® ® t j }t p 1 I t+ Y t �M t f< T.<d �Af fi�.a.K HERE.._.L,�:#Ao,33 x.,?`ORRd;S�rf.(n p e.S.�ONLY �f,; .. . 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