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<br />t~ <br /> <br />STATE OF COLORADO <br />DAMAGE SURVEY REPORT <br />DISASTER RESPONSE AND RECOVERY <br /> <br />3. DECLARATION NO. <br /> <br />2. PPUCANT (State Agency, County, Cit etc.) <br />1:) <br />7~K CATEGORY ("X'~icable8oxJ <br />~ERGENCY OAP!'t, <br />o PERMANENT 0 COD 0 E 0 FOG 0 H 0 I <br /> <br />8. 07;/) kILl7;L;;A idl;;7J;;;;ptiOnJ <br /> <br /> <br />I PANO. <br />I <br /> <br /> <br />1. TO COLORADO DIVISION OF DISASTER EMERGENCY SERVICES <br /> <br />:0820_/.3 <br /> <br />6. PERCENTAGE OF WORK <br />COMPLETED TO DATE <br /> <br />" <br />8A. FACILITY IN OR AFFECTS <br />FL 0 PLAIN OR WET LANDS <br /> <br />DNO <br /> <br />9. DESCRIPTION OF DAMAGE '. . <br />{)q,e//'Jq MIS ~i!'~.s ~Lt::JCND/N~ I TH/S ~DLGt4?A400 #/S~'c:. <br />B~/~dIe t!Ad.s~ ~~/.S ~ BQ/~AJO Aunt;" '$T ,"~ <br />eouSidJ ~t!:S7:l!.U~1PV ~F ;(.JEW OQ'e- 7D t!S4~~Ar~ <br />eR44'S ~4/M dF Sn?uQU'AL <br />10. SC"OFPROPOSEDWORK.I1J~~ A~..:z:F /~~. 7l:) <br />ff~mtfl)e.' · ~LLJ -~L()-eU) ~e;r). <br /> <br />B~LJbe- <br /> <br /> <br /> <br />QUANTITY <br />(a) <br /> <br /> <br />11. ESTIMATED COST OF PROPOSED WOR K <br /> <br />MATERIAL AND/OR DESCRIPTION UNIT PRICE <br />(e) (d) <br /> <br /> <br />COST (dollan) <br />(e) <br />:.-~ <br /> <br /> <br />-/5 <br /> <br />TOTAL" $ S-:.5lXJ- <br /> <br />ELIGIBLE TTACHMENTS <br />OYESDNO <br />CONCUR ATTACHMENTS <br />DYES 0 NO <br />CONCUR ATTACHMENTS <br />OYESD NO <br />qEVIEW lInitia/sand dateJ <br /> <br />15. CONCURRENCE IN REPORT BY LOCAL REPRESENTATIVE (Signature,Agency,dllteJ <br /> <br />16. <br /> <br />,EVI EW (Signature, Agency, dateJ <br />