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<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 />