<br />rr--::s ~ D_fJ~
<br />FEDERAL EMERGENCY MANAGEMENT AGENCY
<br />DAMAGE SURVEY REPORT
<br />DISASTER RESPONSE AND RECOVERY
<br />(See instructions on reverse)
<br />
<br />
<br />Form Approved
<br />oc, OMS No. 3067.0027
<br />3. DECLARATION NO.
<br />FEMA
<br />
<br />
<br />1. TO" REGION.--8~ FEDERAL EMERGENCY MANAGEMEr.lT AGENCY
<br />-----~._._--~-~-.-.---------________r' --- -------- ----- -----.-.-
<br />2. APPLICANT (State Agency, County. City, etc.) I PA NO.
<br />
<br />-W~./..l'~~~""-Ll":..L7o-oP-A <: <:~ __...'..L100..!/ fJ.:u;2
<br />7. WORK CATEGORY ("X" Applicable Box) DSR NO.
<br />CJ EMERGENCY 0 A 0 B
<br />ITl PERMANENT 0 COD 0 E 0 FOG ~H 0 I
<br />8. DAMAGI;.O FACILITIES (Location, identification and description)
<br />'1"I>S~":)"'S Ato"''' LI1/~"'^-' CI2K.
<br />ItPf'RoK. 11'8 '1;I~s Ot=- UTI~ I n'
<br />
<br />.t.l J >f>/!1' /."">'1,/- Poll D
<br />9. DESCRIPTiON OF DAMAGE
<br />
<br />f'o<.. ",-s. 0 Vt;:1!, TVR.fo./~t:>I.tf,e01<CN /MDVE,o Ilil'l' FROs:IOl<1 f ..$L1/:JtC'.s
<br />
<br />4. INSPEC 10 DATE -I
<br />'In
<br />5. WORK ACCO L1SHED BY
<br />
<br />
<br />o CONTRACT
<br />l'9' FORCE ACCOUNT
<br />
<br />25U49
<br />
<br />6. PERCENTAGE OF WORK
<br />COMPLETED TO DATE
<br />IT]
<br />
<br />1E"120&IDN ANa
<br />IAI ~'/.D';"'I\.T dJ,,^, r.,J DA'1AliC D
<br />1- ').J.:"S~
<br />5"/
<br />
<br />%
<br />SA, FACILITY IN OR AFFECTS
<br />FLOOD PLAIN OR WET LA;'OS
<br />
<br />i)(v ES
<br />
<br />o NO
<br />
<br />10. SCOPE OF PROPOSED WORK
<br />~G.J!>"<U:'~ SAMe. /I,PAol'#...r;- ?"to/bS.S 70 "'~R.<lTe..
<br />
<br />-rill Hcfi>~L;i>~ AIfFA ,'su/W;t. .' 5'o/~ llu<><IrE
<br />. ,
<br />
<br />.~I
<br />
<br />#'oWE,/!' ~ IAlES . ~~'-'AJD
<br />Pt~ 1~~rE]:::(ltJIEi:J.
<br />
<br />QUANTITY
<br />ial
<br />
<br />UNIT
<br />(bl
<br />
<br />11-:- ESTiMATED COST OF PROPOSED WORK
<br />MATERIAL AND/OR DESCRIPTION
<br />Ie)
<br />
<br />UNIT PRICE
<br />(d)
<br />
<br />','
<br />
<br />.> ;,
<br />
<br />1,1,
<br />
<br />._.~~~:
<br />
<br />COST {dollar#
<br />(el'~':::.,
<br />-~, -"" ;,.- ~ ,"",
<br />
<br />,
<br />,
<br />
<br />, '" ,.f t; -'- ~
<br />
<br />
<br />\.
<br />
<br />, 1?AJ'"YMJ"-AJ--r-
<br />~,_~__.___~__~_~$"Q7A<:'"
<br />I t;,u6IA)#F~lItl6 '(J~'J--~u'-~
<br />
<br />
<br />4.l3B
<br />
<br />i--...t--------
<br />_.~---'
<br />
<br />12. EXISTING INSURANCE (Type) ; AMOUNT
<br />
<br />NON c:... . .. .____.._.:,$,._-0-
<br />13 RECOMMENDATION BY FED AL INSPECTOR (Signature, Agency, dare)
<br />
<br />~ .~~ t"
<br />_ . r e ifll.ff
<br />14. CO CURRE CE IN REP~Y STA E I S CTOR (Signature, Agency, date~ ()) CONCUR
<br />Zb- _ .1--- _ . _ /1 R/tJ.-,I'< ____ _ ,f';';l/ ~J _ ES[]..~O
<br />15. 'CO~RRENCE IN REPO L REPRESEf;fTAmE (Signa,",e, Age y, da / r ,. NCUR
<br />
<br />~.-< (, .' ,L--d~--+yi-4-fC+.--.--S;' :21-r.~/-_----~'-' ~ONO
<br />,6:"'''' FED"ERAL.~EVrEW (Srgnatute, Agency, date r J . /! FEMA REVI EW (In/tials and date)
<br />I
<br /><r I.. I//f'.<./....J.
<br />
<br />CU TOTAL'" S
<br />
<br />- -eLIGIBLE ~
<br />YES I::::J NO
<br />
<br />60 <II
<br />ATTACHMENTS
<br />
<br />ATTACHMENTS
<br />
<br />ATTACHMENTS
<br />
<br />
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