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<br />..J- A...> J. ,j Iii ~ ( ~/ - l' ~\ I 0",,/ ~- / I 01\/18 N0. 3067.UU21 <br /> <br />FEDERAL EMERGENCY MANAGEMENT AGENCY <br /> <br />DAMAGE SURVEY REPORT <br /> <br />DISASTER RESPONSE AND RECOVERY <br />(See instluctions on reverse) <br /> <br />v <br /> <br />- OK'!' 0 <br />4. INSPECTION D^TE <br /> <br />3. DECLARATION NO. <br />FEMA <br /> <br />2. APPLICANT (State Agency, County. City, ete.! <br /> <br />~~.F1I"'Cr: (j n- np A ~~rY' <br />7. WORK CATEGORY (UX" Applicable Box) <br />C EMERG ENCY r.:J A [J B <br />CD PERMANENT C C CJ DOE 0 FOG ~ H 0 I <br /> <br />8. DAMAGED FACl L1TIES (Location, identification and description) <br /> <br />1. TO'" REGION....8_ FEDERAL EMERGENCY MANAGE'>1ENT AGENCY <br />-----r-..--~ <br />I PA NO. <br />I COO-<7'C<?oQ <br />DSR NO. <br /> <br /> <br />r <br /> <br />o CONTRACT <br />ry-FORCE ACCOUNT <br /> <br />25184 <br /> <br />6. PERCENTAGE OF WORK <br />COMPLETED TO DATE <br />IT! <br /> <br />% <br /> <br />tt, F.e '" ~~E- S rl2rJC nil::? E. - (~'t_ot/ ~4NS. L,,,,~) I <br />li1~r ~J:' 9M'i,..:C'~P IAI SECTltMf 9. TiHU^,<i'I'P 2.NtNZTn E<I.J(;. I <br />,vCrT _ . ~ <br />9. DESCRIPTION OF DAMAGE .. <br /> <br />SA. FACILITY IN OR AFFECTS <br />FLOOO PLAIN OR WET LANDS <br /> <br />DYES <br /> <br />NO <br /> <br />r.Jnur> Pb'-~ b,,srVRB,;.D <br /> <br />&'1 ~/(.. <br /> <br />s;:'L I/" <br /> <br />10, SCOPE Of PROPOSED WORK <br /> <br />Re-ADI#N ft,'k <br /> <br />.j ,-1'1. .'.;1V s ::<~. <br /> <br />L/r;r <br /> <br /> <br />QUANTITY UNIT <br />lal 1111 <br /> <br />11. ESTIMATED COST OF PROPOSED WORK <br />MATERIAL AND/OR DESCRIPTION <br />, {el <br /> <br />UNIT PRICE <br />(d) <br /> <br />COST (dollars) <br />(el <br /> <br /> <br />~.'. '. <br /> <br />c4. <br /> <br />'~" ;.~ <br /> <br /> <br />I <br /> <br />....a~ <br /> <br />12. EXISTINGIN~~FlA~CE (T;lo~__l~:ou~..-=--j~_TOTA:~ -;---;;~i_~~:= <br /> <br />13. RECOMMENDATION BY FEDERAL I ECTOR (S,qnarUfl', Agencv, dat(') I ELIGIBLE @] ATTACHMENTS <br />~ /?/ ..L-!.. ,/ tt '-, <br />14. CONINR?ilO\j'f T SPEc-r61l (S1->a~-:AgeneV'dateI8~c2 ,1..7---- co~J~~-" NO ATTACHMENTS <br />_ A'L 'Y. ___tJd.M _jJj~.l/t'; - - XI Y.ES~r<O. ---- <br /> <br />IS.. j/ ....~ ENCE~N ~EPOR<,ES~~:S~N~~~; (~g~:'::~n::-.;:;__ __,___lEf~~~~oj ATTACHMENTS <br /> <br />1CFEOERA EVI EW (Signature, Agency, date) fFEMA REVIEW (Initials and date) <br /><74( ?/:n/rl : <br /> <br />).. (i,.'AlE rll4JGI<) /... .t \ <br />_U t "',(1 i= fl.::rp. I<~ ~'/-48d'. <;"''41 J <br />~(J; (l"'JIt/OJj6'1~}...--- <br />.....A.J, <br />~ TON' 'P. tJ <br />..t.- -To", P t.L <br /> <br />....1S. (J 0 <br />d--5D- <br /> <br />" <br /> <br /> <br />5'B <br /><; <br />tLJ <br />G. <br /> <br /> <br /> <br />, ".: ",' :' - , l . ,: ~ <br />