5.e) PUP, Chilkoot Velo Bike Time Trial Race Meeting Date: 06/21/2011
Agenda Item: � � �
City Council Agenda Report
City of Scandia
14727 209`�' St. North
Scandia, MN 55073 (651) 433-2274
Action Requested: Consider approving the application of Chilkoot Velo for a park user
permit to hold a bicycle time trial race on Saturday, July 23 using the
Hay Lake Park picnic shelter for registration and finish line activities.
Deadline/Timeline: N/A
Background: • Details of the event, including the route for the bike race, are
included in the application materials, attached
• Because the event is expected to draw over 100 people, Council
approval of the park user permit is required. The application states
that 200 participants and 100 spectators are expected.
• Similar events were held in 2009 and 2010 (sponsored by other
cycling organizations) which used the Community Center/
Warming house site. Unlike the Community Center site, the Hay
Lake site does not have restrooms. The city provides a single
portable toilet at this location.
Recommendation: Staff recommends that the following conditions be attached to
approval of the park user permit.
1. A minimum of 3 portable toilets shall be provided on the Hay
Lake Park grounds.
2. Organizers shall coordinate their route, and follow any
recommendations for traffic control during the event, with the
Washington County Sheriff's Department.
3. The location of any tents, stakes, signs etc. shall be approved
in advance by the City's Public Works Supervisor. Event
organizers shall request any utility locates that may be
required.
4. Event organizers shall provide trash containers and remove
and properly dispose of all waste on the day of the event.
Attachments/ • Park User Permit Application
Materials provided:
Contact(s): Mike Lyner, 651 360-1533
Prepared by: Anne Hurlburt, Administrator
(chilkoot velo park user permit)
Page 1 of 1
06/17/11
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SCANDIA
14727 209'"Street North
Scandia, Minnesota 55073
(651)433-2274 www.ci.scandia.mn.us
Park User Permit
Type of Permit Requested (Check all that Apply):
Extension of Park Hours Erection of Structures Sale of Articles
Signs/Placards X Gathering> 100 People** Discharge of Fireworks**
**Require Ciry Council Approval
Name: CHILKOOT VELO (c/o MIKE LYNER)Phone: 612 .360 . 1533
Street Address: 1031 ABBOTT ST W E-mail: MIKE.LYNER@RSPARCH.COM
City/State/Zip: ST I LLWATER, MN 5 5 0 8 2
Date(s)of EvenU Use: SAT, 2 3 JULY 2 O 11
Description of Use (including approximate number of people):
USA CYCLING / MN CYCLING FEDERATION - BICYCLE TIME TRIAL RACE
PARK' S PARKING, SHELTER AND RESTROOM NECESSARY FOR REGISTRATION
AND AWARDS AREA.
Acknowledgement/Signature:
I hereby acknowledge receipt of a copy of this application form and Ordinance No. 115,Establishing Rules and
Regulations for Scandia Parks,and agree to abide by the ordinance and any other conditions that the City of
Scandia may place upon issuance of this permit.
Si nature: ��`�" Date: 6/16/11
Conditions of Approval:
Ci Re resentative Si nature: Date:
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S�ANDIA
14727 209`h Street North
Scandia, Minnesota 55073
(651)433-2274 www.ci.scandia.mn.us
Park Shelter Reservation Form
Location to be Reserved: Hay Lake Picnic Shelter X Warming House
Time
Date to be Reserved: SATURDAY 2 3 JULY 2 011 (to/from): 7 : 0 OAM - 2 : 0 0 PM
Name: CHILKOOT VELO (c/o MIKE LYNER) Phone: 612 . 360. 1533 (M)
Street Address: 1031 ABBOTT ST W E-mail: MIKE.LYNER@GMAIL.COM
City/ State/Zip: STI LLWATER, MN 5 5 0 8 2
Description of Use
(including approximate
number of people): 10 0
Acknowledgement/Signature:
I hereby acknowledge receipt of a copy of this reservation form and the Park Shelter Reservation Policy,and
accept the responsibilities listed therein. I understand that violation of the policy may result in withholding of
any required deposit and/or the denial of future use of the facilities.
Si nature: Date: 6 15 11
Ci Re resentative Si nature: Date:
Rental fee: Date fee paid:
Sales tax: Deposit amount:
Total: Date paid:
EVENT NAME SCANDIA TIME TRIAL PERMIT#
EVENT DATE(S) SAT, 23 JIILY, 2011 SET-UPlTEAR-DOWN DATE(S) ($25/DAY)
P �-'~ ROAD/TRACK/CYCLOCROSS COMPETITIVE EVENT PERMIT APPLICATION
„ (REV.2011)
n `� 210 USA Gyding Poinf,SUite 100 ColOrdtlO Springs,CO 80919-7115'ph:719V43413200"f.719/434�.300'Www.use(.yding.org
�``�� Fa compe0tive everds only.ApplicaUa�s must be subRrtted to USA Gycing�o later lhen soc w�eelcs in advar�oe o(ihe everri dade.
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NRc uci
(�STATE Crite�ium Raed Raoe Tradc Raoe Series Race Co�egiate LA,IORS
�LOCAL (.ydoanss (�Time Trial OStage Race DAmateur Only ❑Open(Pro-Arn) �Other
. - � .• . .- � . . .
EVENT LOCATION(city,state) SCANDIA MN
SPONSORING USA CYCLING MEMBER CLUB(S)[UP TO 5 CLUBS) I LKOOT 'VELO
PROMOTER CHILKOOT VELO
PRiMARY CONTACT M I KE LYNER TELEPHONE( � 612-3 b 0-153 3
ADDRESS 1031 ABBOTT ST W F� 1 ) 612-677-7499
cmr aTILLWATER sttire MN ziP 55082
EVENT WEBSITE WWW,CHILKOOTVELO.COM E-MAIL MIKE.LYNERQGMAIL.COM
Feel tree to chedc your informa6on on the USA CycGng website at www.usacyding.ag.
PERMIT FEE WORKSHEET For all Road/Track/Cyclocross CompeliUve pertnkted events.Canceflatlon o(event will result in a$50 fee.
. . • •.. . �. •
A $10,000+ 7%of total rize list rwei �e��8t s x�x,t s =P��Fee
B $5 000-$9 999 7% of total rize list To►ei e r�s z�%=s =PertNt Fee
C $2.000-$4,999 7% of totai rize tist Yo►e� e a�s�s x�sc=# =P���ee
� ��JOa-��,�99 $rJ� 8f d& Number ot Oa s x S50= =Pemitt Fee
E < $0-$499 $25 er da Num�or na 1 x szs=s 2 5 =Permit Fee
Set u date $25 er da Nurnber of Da x z3= �Permt�Fes
. . .
. �
A traihing rat�serles is a sequence o!race meets oi the same kind conducted on a regular Permk Fee=
basis at ihe seme Oocatiorar>>llme and da oi tne week stale cham onshi series are NOT 5et-u�ear-Down fee=
Y � Pf P Lete tlir�g ise=(wlthin 8 weeks oi event) +$50
eligible). A prize Ilst oi less than 5499 per day may be oi(ered, Fee:1-3 days=515.00,430 Rush fi�ing�ee=(wlthin 2 weeks of event)+$100
days=550. All State Championships�e al least a category D evenl Aq riders musl be Paper processing fee +S25
licensed and sign waivers. Promoters pay$3.00(per rider per day)for insurance coverage. TOTAL PERMIT FEE DUE: $2 5 . 0 0
INSURANCE SURCHARGE is 53.00 per rider per day and must be submitbed in Tull with post event report.
All riders must be licensed and sign waivers.
NO REFUNDS ON RUSH FlUNG FEES,LA7E FlL1NG FEES,ORAUTOlMOT01NSURANCE FEES
NO REFUNDS NO IXCEP'iIONS
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Form ofpay inent• ❑Check O Monay Order ❑VISA 0 MasterCard /��'r`
Credit Card#: 4 718 3 0 0 0 U 15 9 4 7 2 9 Expiration Date: 6/13 Signature: �/^
Cardholder Name:MI CHAEL R LYNER Cardholder Address: (ABOVE) �
The undersigned,as agent of the sponsoring dubs and promoter(collectively,"Organizers"),having read the information in the accompanying permit
padcet,agree to the same,and agree to abide by and enforce the rules,regulations and declsions of USA Cycling,Inc.(USAC)and its agents,offiaals
and member associations.The Organizers agree to defend,to hold harmless and to indemnify USAC and its agents,officials and member associations
against any and all costs,daims,legal fees and liabilities which are connected with or arise direcUy or indirectly out oi the preparation for or conduct of
the above event(s);to cooperate with USAC and its agents in the event of any personal inJury or other daims andlor other legal action(s)arising out of the
above event(s)and to make available to USAC,upon request,al!records of the event(s)induding,but not limited to,partiapant entry forms and waivers.
The Organizers agree to maintain copies of the event participant and volunteer waivers for a minimum of 10 years and acknowledge this is a condition of
the Organizers'insurance coverage.It is understood and agreed that USAC makes no warranties,expressed or implied,to the Organizers,to entrants,
competitors,volunteers,spectators,or to any other person. USAC and its member associa6ons are not promoling organiza6ons. Organizers understand
any peanit issued by USAC is not assignable to another event.By signing this form,Organizers agree that Organizers are responsible tor all insurance
surcharges and race fees due to USAC. This permit does not c�eate a principal-agent relationship between the parties thereto. I undershdnd that'rfl would
bke t�insure my non-owned�ired autanobiles andlor motorc.ydes with USAC,I must oomplete and submit the na}o�rrt�edlhired autanob�e andla motacyde insurance
application witl�accurate peyment. I also undersland that iF I do NOT complehe and submit on time 1he na►�ownedlhired autorrab�e andla matac.yde inaxance app6ca-
tion,any au6omobiles andla rnotacydes at my event vai not be�ed by USAC ir�uranoe. Organ¢er wi be rpsponsible ia reimbursing USAC related to any ACH
Retums,aedit c�d chargebadcs,other d�sputes,or disaloNranoes assoaated w�h funds ootleded ar�d prooessed by USAC on Organ¢er's behalf.
Organlzers Signature Date
Regional CoordinatorlLocal Asaociation Date
USAC Authorized Signature Oate
DISTRIBU710N: WNITE-USAC VELLOW-INSURANCE PINK-REGIONAL MANAGER GOLO-PROMO7ER
� REQUEST FOR CERTIFICATE OF INSURANCE
P ���A AND ADDITIONAL INSURED
a`' G�'""� FOR ALL USAC PERMITTED EVENTS
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yC L�� Applications must be submitted wfth the permit unless information is not yet available.
Application must be reoeived prior bc the avent or it will not be processed.
Mail to: ♦ USA Cycling • 210 USA CycJing Point, Suite 100,Colorado Springs, CO 80919-2215 ♦ Ph: 719/434-4200
• Fax: 719/434-4300 ♦ Emaii: membership@usacycling.org
Event Permit#
Name of Club/Organizer: CHILKOOT VELO Club/Organizer#: 121�3
Phone Number: 612-360-1533 Fax: 612-677-7499
Event Name: SCANDIA TIME TRIAL Event Date: 23 JULY 2011
Event Location: SCANDIA MN E-fllail: MTKE.L�TER�?GMAIL COM
List all parties who are requiring that they be named as additional insured for this event. THIS IS NOT VALID WITHOUT A
RELATIONSHIP INDICATED. Examples of relationship categories include landowner, permit holder(govemmental bodies
which have issued permits), sponsor, municipality,etc. The first five additional insured parties are FREE. You may
request as many more additional insured partles as necessary for an additional administrative fee of;5 each (please
attach addidonal copies of this page as needed). PLEASE PRINT. NO REFUNDS NO EXCEPTIONS
i) Name WASHINGTON CO. c/o CAROL HANSEN phane (651) 430-4300
Address 11660 Myexon Road North Relationship ROAD USE PERMIT GRANTER
C�� Stillwater �� MN Zip 55082
2j Name CITY OF SCANDIA c/o BRENDA EKLUND php�e (651) 433-2274, EXT. 100
Address 14727 209th St. N. Relationship REGISTRATION P.REA
�jty S�AND Ip` State � Zip 5 5 0 7 3
3) Name MIKE LYNER Phone 612-360-1533
Address 1031 ABBOTT ST W Reladonship PROMOTER CONTACT
City STILLWATER S�� � Zip 55082
4) Name �DY MOSES Phone 651-439-6552
Address 1009 5th Ave S Relatlonship PROMOTING CLUB PRESIDENT
City STILLWATER State MN �p 55082
5) Name Phone
Address Relatlonship
City State Zip
Have you entered into any agreement,contract,or permit in conjunction with this event that contains assumption of
Ilability, indemniflcation, or hold harmless language? YES X NO
If yes, please forward a copy of the document with this Request for Certificate of Insurance and Additional Insured.
NO REFUNDS NO EXCEPTIONS
M:/2011 Membership Forms/2011 Request for Cert of Inswance and Addirional Insureds.doc Rev 11/10
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Race Categories: Junior Junior Women: Masters Men: Masters Tandem:
Girls: Boys: Women: Men:
10-14 10-14 C2t 1/2 4O+ non-ROY C8t 1/2 35+ Open non-ROV
15-18 15-18 Cat 3 Cat 3 50+
Cat 4 Cat 4 60+ non-ROY
Cat 5 non-ROY
Registration: JUNIORS RACE FREE (including free 1-day license)**
Pre-registration Fee: $25(before midnight July 21, 2011)for USAC-licensed riders.
On-site Registration Fee: $35 for USAC-licensed riders.
One-day licenses are available on-site at an additional fee.
Registration opens at 7:30am and closes at 8:45am on Saturday at the Ham lake School Park
shelter(2 miles south of Scandia, see attached map)
PLEASE NOTE: Toilets will be provided...public urination may result in disqualification.
Start Times: 10k junior riders start at 9:OOam
20k riders start at 9:15am
40k riders start at 9:30am
(40k pre-registered riders will be able to view their start times after 6:OOpm Friday 22 July 2011)
Race Course: Scandia Loop: (See the attached map.)
• Start/finish line is north of 195th Street on Olinda Trail (CoRd 3)
• South on CoRd 3 (Olinda Trail N)to CoRd 4 (170th Street North)
• West on CoRd 4 (170th Street North)to CoRd 15(Manning Trail N)
• North on CoRd 15 (Manning Trail N)to Mayberry Trail N
• East on Mayberry Trail N to 195th Street N
• East on 195th Street N to CoRd 3 (Olinda Trail N)
Juniors (10-14):10k out and back on Olinda Trail, U-turn at 170th Street N (Co Rd 4)
Juniors(15-18)and Masters 60+: Single loop, approximately 20k.
All others: Two loops, approximately 40k.
Olinda Trail, 170th Street, and Manning Trail stretches have wide, well-paved shoulders.
Mayberry Trail and 19 Street stretches have no shoulder but are well-paved with light automobile
traffic.
Rules: All USAC rules apply. Helmets are mandatory; sleeveless iersevs are now OK so bring vour
triathlon friends). No farings allowed. The course is not closed to auto traffic;the yellow line rule
will be in force.As a quideline thisyear,we would also like to sugaest usin4 the USA Triathlon
rule that all riders must stav within 1 m (-3ft)from the curb unless overtakin4. The first rider will
depart at 9:OOam. Subsequent riders will depart at 30 second intervals. All riders must check-in,
sign the release, and pick up numbers before 8:45am. Riders must be at the start-line staging
area 3 minutes prior to their scheduled start time.
Award Ceremony: An award ceremony will be held near the registration area approximately 30 minutes after the
last rider crosses the finish line. Medals will be awarded to the top rider in each category.
**Money typically associated with category prizes is being used to fund the'Free Junior Racing'
emphasis of this event.
Contacts: Promoter: Mike Lyner Club President: Randy Moses
(612)360-1533 (651)324-0789
mike.lvner(a�qmail.com rmbikes2(o�qmail.com
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P r�-"• ROAD/TRACK/CYCLOCROSS COMPETITIVE EVENT CHECK LIST
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^��i,� USA Cycling Inc.,210 USA Cycling Point,Suite 100,Colorado Springs CO 80919-2215 Phone 719/434-4200 Fax 719/4344300
htt�://www.usacvclina.ora
All questions need to be answered by the Event Organizer before submitting to USA Cycling for permittin9.This form is not required for non-mmpetitive events,training rides,
camps or clinics.Prior to the race,the Chief Referee must mmplete his/her event check list questions.Failure to comply with the provisions agreed upon on this form may
result in cancellation of the permit or the Chief Reteree canceling the event on race day. The Chief Referee will return this fortn with his/her report on the event to USA
Cycling.
RACE NAME: SCANDIA TIME TRIAL PERMIT NO.
LOCATION: Ciry: SCANDIA, MN State: EVENTDATE(S): 23 JULY 2011
EVENTORGANIZER: CHILKOOT VELO (MIKE LYNER) STATE:
SCHEDULED EVENT START TIME: FINISH TIME:
� �
1. Identify the person(s)responsible for completing the
Occurrence Reports to be submitted to the Chief Referee: MIKE LYNER
2. Estimated number of event participants and spectators: Participants: 2�� Spectators: 10 0
ORGANIZER CHIEF REFEREE
3. Event Flier: YES NO YES NO
a.Does the Flier list: • event contact information? • race location? X
b.Does the flier list: • entry fees? • prize list? • registration time? X
c. How will/was the flier distributed? WWW.MCF.NET
4. Are copies of the Third Party Insurance Certificates attached?
Organizer Comments:
Referee Comments:
5. Organizer's Support Staff:
a. How many support staff will be/were present?
Organizer Comments:
Referee Comments:
6. Medical Support:
a. Will an ambulance be on site? X
b. Has a local hospital been contacted? X
c.Will medical locations be set up? X
d. Separate medical plan checklist included? X
Organizer Comments:
Referee Comments:
7. Event Entry Fee and Participant licensing:
a. Who will be responsible to check annual licenses at registration? VOLUNTEER
b. Who will be selling one-day licenses? VOLUNTEER
c. Who will be selling annual road/track memberships? VOLL7NTEER
Organizer Comments:
Referee Comments:
� ����
8. Event Permits:
a. Has written permission been granted to use the course? X
b. Has written notice been submitted to property owners(private or gov't)? X
c. Have course residents been notified? X
d. Will automobiles be used in this event? If so, how many? X
e. Will motorcycles be used in this event? If so, how many? X
Organizer Comments:
Referee Comments:
YES NO YES NO
9. Spectator and Race Control:
a. Have course marshall locations been set? X
1. Major intersections X
2. Intersecting roads X
3. Locations open for business(heavy traffic) N A
b.Will police be present? X
Organizer Comments:
Referee Comments:
10. Course Closure(complete a, b, or c):
a.Total Closure X
b. Rolling Closure X
c. No Closure
Organizer Comments:
Referee Comments:
11. Prizes and Award Presentation:
a. Is there an identified prize list for the event? X
b. Is the prize list stated on the event flier? X
c. Has cash and merchandise been separated on the flier? N A
d. Is there a plan for distributing the awards? X
e.Will there be an awards ceremony? X
Organizer Comments:
Referee Comments:
12.Communications:
a.Amateur Radio Operators X
b. Citizen Band Radios X
c. Business Band Radios
d. Cellular Telephones X
e. Will/did vehicles have radios? X
Organizer Comments:
Referee Comments:
13. Signage:
a. Signs at intersections? X
b. Signs directing participants to course location? X
c. Start/Finish Line identified? X
d. Feed zone identified?
e. White flag/sign at 200m? N A
f. Have hazards on course been clearly marked?
Organizer Comments:
Referee Comments:
Organizer's Signature Date 12 MAY 2 O 11
Chief Referee's Signature Date
RC/LA Signature Date
M:/2011 Membership Forms/2011 Road Track Cyclocross Competitive Event Check List.doc Rev.11/10
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��`� EVENT MEDICAL PLAN AND CHECKLIST
PLANNING FOR MEDICAL EMERGENCIES
Competitive bicycling can be a very exciting and fast-paced sport full of action, thrills and even
spills. In planning an event, event directors and their staffs must consider not only how they will
handle minor injuries such as cuts and bruises, but also major catastrophic injuries that will
require full attention from trained medical personnel.
In the planning process for any event, time must be spent considering medical emergencies. Will
there be trained Emergency Medical Technicians, doctors and an ambulance on site? Or, will the
event rely on First Aid administered by volunteers or staff? How far is the hospital? Is there air
ambulance service available? Can emergency vehicles reach all points on the course? These are
only a few questions that should be carefully considered in the development of a full medical plan
that can be on site and referred to in an emergency.
At an event, designate one staff member as the medical coordinator. This person will be
responsible for the implementation of the medical plan and oversee any emergency evacuations.
Medical plans should cover all participants, spectators and staff and cover all days of the event,
including any officially designated practice days. Any occurrences at an event, no matter
how seemingly minor, sf�ould be noted on a USA Cyclin� First Report of Occurrence
and submitted to USA Cycling with your post event mater�als.
USA CYcling encoura es event directors and organizers to use this form for designing
a medical and even� emerg ency plan. Organ�zers are welcome to add addifional
information if necessary. Please keep a copy of this list on hand at your event for
reference in an emergency.
USA CYCLING
210 USA CYCLING POINT, SUITE 100
COLORADO SPRINGS CO 80919-2215
Phone 719 434 4200 � Fax 719 434 4300
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'�`'�`� EVENT MEDICAL PLAN
EVENT SCANDIA TIME TRIAL DATE 23 JULY 2011
1. Will there be an EMT or ambulance on site? Yes X No
If not on site, how will emergency medical staff be notified?
Pay Phone X Cell Phone Radio Other:
2. Are there event staff or certified volunteers with Red Cross First Aid training? Yes X No
If yes, what training? Basic Advanced - Identify staff:
3. Is there a First Aid kit on site? X Yes No
4. Will police or security services be on site? X Yes No
5. Will emergency medical stafF at event site be clearly identified? N/A Yes No
6. First aid and emergency medical stations identified? X Yes No
7. Does course design allow easy access for emergency vehicles? X Yes No
8. Describe emergency medical transportation? AMBULANCE
9. City/Location of nearest hospital: OSCEOLA, WI -OR- STILLWATER, MN
10. Distance from event: 10 or 15 Miles 10-15 Minutes
11. Has hospital been notified of the event? Yes X No
12. Is emergency air transportation available? X Yes No
Response time: •' Minutes
13. How will air transport be notified? Phone Radio X EMT
14. What is the plan for suspending or postponing the event if a serious injury occurs?
VOLUNTEERS AT ALL CORNERS, START AND FINISH WITH CELL PHONES
15. Who will compile and submit USA Cycling First Reports of Occurrence for all injuries at the event to the Chief
Referee?
X Event Director EMT/Medical Staff Other(specify):
NOTES:
HOSPITAL PHONE NUMBER: (6 51) 4 3 9-5 3 3 0 (non-emergency�
AMBULANCE PHONE NUMBER: (6 51) 4 3 9-5 3 3 0 (non-emergency)
POLICE/SHERIFF PHONE NUMBER: (651) 439-9381 (non-emerqency)
PHILADELPHIA INSURANCE COMPANY: PHONE 1-800-765-9749, FAX 1-800-685-9238
ADDITIONAL INFORMATION:
M:/2011 Membership Forms/2011 Event Medical Plan and Checklist Rev. 11/10
,
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Copyright m and(P)1988-2009 Microsoft Corporation and/o�its suppliers.All rights reserved.http://www.microsoft.com/mappoinV
Certsin mapping and direction dala m 2009 NAVTEQ.All rights reserved.The Data tor areas of Canada includes information taken with pertnission from Canadian authorities,including:�
Her Majesty the Queen in Right of Canada,��ueen's Printer tor Ontario.NAVTEQ and NAVTEQ ON BOARD are trademarks of NAVTEQ.�2009 Tele Atlas NoM America,Inc.Ali nghts
reserved.Tele Atlas and Tele Atlas North America are trademarks of Tele Atlas,Inc.0 2009 by Applied Geographic Systems.All rights reserved.