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<br />FEDERAL EMERGENCY MANAGEMENT AGENCY
<br />
<br />DAMAGE SURVEY REPORT
<br />
<br />DISASTER RESPONSE AND RECOVERY
<br />(See instructions on reverse)
<br />
<br />~
<br />
<br />OMS Nu, 3067-0027
<br />3. DECLARATION NO_
<br />FEMA
<br />
<br />~
<br />
<br />1, TO" REGION --R..... FEDERAL EMERGENCY MANAGEMENT AGENCY
<br />.-.- -----------.,---.- ------------ --.--
<br />2. APPLICANT (Sra'e Agency. Coun'v. Ci'V. ere.! I PA yo.
<br />---. ' . ~.._----~-- : . jJ~f)l'>(.)l)
<br />7. WORK CATEGORY "X" Applicable Box) DSR NO.
<br />c?<€MERGENCY ~ !
<br />OJ 0 PERMANENT C is "0 D E 0 FOG 0 H 0 I
<br />
<br />8. DAMAGED FACILITIES (Location, identification and description)
<br />
<br />CO Il..J g-;2. '-It /:,,!-,,"" , "'0,,):' .su'1fA(e
<br />
<br />
<br />o CONTRACT
<br />S(FORCE ACCOUNT
<br />
<br />24307
<br />
<br />6. PERCENTAGE OF WORK
<br />COMPLETED TO DATE
<br />
<br />I2l %
<br />
<br />8A. FACILITY IN OR AFFECTS
<br />FLOOD PLAIN OR WET LANDS
<br />
<br />~ES
<br />
<br />ONO
<br />
<br />9. DESCRIPTION OF DAMAGE I f ~ I I j
<br />j{ock::. . de.. 0", (loAD lip/O,y 300/ '1v"'5"cI~ (we",.. f2.AO
<br />/.<~~OIJ( 3xSO/) I1P;Zg,g f~,,,- JlYM"/ ArcvA.:''';', J. r/,'i'c/( /~,"o
<br />("' -.) j,
<br />
<br />MP2.3
<br />
<br />10, SCOPE OF PROPOSED WORK
<br />
<br />.At!>",1' /oc/',l"",.J cl,J. t"II,?
<br />/
<br />('^,l~t' /~ ~o....)) J.~
<br />
<br />C k/l.t: /l "AO /.. "n'I..,e. I1U I"!,S /J.f
<br />CkPAI!. cj"l'~ I.:. JV""_;-..."er1~'<'~<',Jo ~t'~l'J fA/",,j,.jJt,
<br />of ::,/.J~~ 11 f !>-('he;J->po.JS;t/, :s,le
<br />
<br />11. ESTIMATED COST OF PROPOSElJ WORK
<br />--~---------- - ~-_.,._----~----------~---
<br />MATERIAL AND/OR DESCRIPTION
<br />Ie)
<br />
<br />UNIT PRICE
<br />Cd)
<br />
<br />QUANT"iTYlUNrr---
<br />Cal Cbl
<br />
<br />
<br />'L._
<br />
<br />
<br />-r83
<br />
<br />jJ('V bark ~a "'_
<br />/ .
<br />..3.S;f In /.l J 0,
<br />. S L;.)L.. ~/",O..JA.J( -,-~--~.
<br />-~--~-!r-(.AiL~~. i~ I..~":s
<br />
<br />/J.LJ
<br />,
<br />//t9
<br />...:2..936
<br />
<br />12. EXISTING INSURANCE (Type)
<br />
<br />; AMOUNT ... S
<br />I $ rn TOTAL
<br />----- --SP-ECTOR (Signature, Agencv, d~-t;}--~ - - ~.~--- -E-UGIS'LE--tID
<br />-1-1 hi 1)._-, Ul.>rES 0 NO
<br />INS ECTOR (S,gnature, Agency, dateJ CONCUR
<br />'_n ~~~..-L. ~--_,~/.I3/?11~.1>_g!"O
<br />L REPREser1VE (Sign;r;;;;A;;~eJ 7 CONCUR
<br />
<br />. naW'e. A nev, d~tej~~-' Z.~!i: ;'~~'7lniti;;;sand;::;'S D NO
<br />I
<br />I
<br />
<br />.~~-
<br />----- - ~-
<br />
<br />-~- -
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<br />-.-,-----~ ----
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<br />
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<br />13.
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<br />14.
<br />
<br />ATTACHMENTS
<br />
<br />ATTACHMENTS
<br />
<br />FEMA Form 90-52, JAN 81(FormNly HUD Form 484)
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