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<br />OMB
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<br /> ,./ No. 3067-0027
<br /> FEDERAL EMERGENCY MANAGEMENT AGENCY 3. DECLARATION NO.
<br /> DAMAGE SURVEY REPORT FEMA 7'7' 0" A (U
<br /> DISASTER RESPONSE AND RECOVERY 4, INSPt'y;rtATE
<br /> (See instructions on reverse) 8 B "2-4-
<br />1, TO" REGION g FEE!ERAL EMERGENCY MANAGEMENT AGENCY 5. WOR!< ACCOMPLISHED BY
<br /> Ga CONTRACT
<br />2. APPLICANT (State Agency, County, Fity, etc.) I PA NO. o FORCE ACCOUNT
<br />(. ......, ,.- 0.......,,...; (...-It;./ X (?" -- Cu I '. ! ....</\. -\
<br />7. WORK CATEGORY (UX# App/i~(JlfIe Box) I DSR NO. .~ 6. PERCENTAGE OF WORK
<br /> o EMERGENCY 0 A 0 B' I COMPLETED TO DATE
<br /> I P71/1/17
<br />m Ql PERMANENT 0 C c;J DOE @.F oG oH 01 I ...), 1""-t IT!
<br /> 6 %
<br />8. DAMAGED FACILITIES (Location, identification and dBSCriptionJ BA. FACILITY IN OR AFFECTS
<br /> (? ~ "V ~~Yt S~~1lt...{ !l e-1 t."7t: v~ .'It L 0 <. A-1"l )0 ....,....(-'P"Z..." FLOOD PLAIN OR WET LANDS
<br />Z ~''-c--r r-r-~';'" 7b__.-....J .~ eM" ~ "".,-,.., (...............,,"'- r <'T G;J YES oNO
<br /> ~ v'-~"" C ,.." A-o- " ./ " 2l&'" A- .' r--r-
<br />9. DESCRIPTION OF DAMAGE
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<br /> ',-V /? i:"-rL.....I\.A:,.ol tC' . B/lL-~ rl <,., r~ 17-+";- 5iJ. '-L'-'I41.; <-..J, --..it.< '-' J4..-{..\..-J) ....,.........,.., 6"'~,...r-~ IA..I /'4tfC,:-
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<br /> D'~<'/~~("-6 I'\7r .~ " I5c~ .c..-u-..;' iJ-,
<br />10. SCOPE OF PROPOSED WORK .
<br /> rt(..~........1.E 5''''1 F/l"-'-' /2""",... V("I,I( (l ~_A-<'~ S t?,'. ~ l~ ,d ~rT' ---o......~'
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<br /> 11, ESTIMATED COST OF PROPOSED WORK
<br />OUANTlTY UNIT MATERIAL AND/OR DESCRIPTION UN IT PR ICE COST (dollars)
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<br /> Sc;:.......o -,.. l.. ))n...... L ..+r .,
<br /> " ~-----
<br />12, EXISTING INSURANCE (Type) I AMOUNT TOTAL .. $
<br /> NOr0"<:::""" I $ ill 2- +.9 1:''-'
<br /> --- u__
<br />13. RECOMMENDATION BY FEDERAL INSPECTOR (Signature, Agency, date) ELIGIBLE ~ ATTACHMENTS
<br />[lL-i/L.~~( 'l--c v~ (.-{?AO::/ "'18 't- 4J YES 0 NO
<br />14, ~~U~Z:lPORT BY Sl; E INSPECTOR /SignaMe, Agency. da'e) CONCUR ATTACHMENTS
<br />1---' , /--4,J..{ ~.10<: ' I I, ,...- ~YES 0 NO
<br />15. CO CU C I~ EPORT BY i.{)CAL RE~ESENTATIVE (glgdtu;/' Agency, date) CONCUR ATTACHMENTS
<br /> _/.:;?/ _ .' /,/ -r /).'.1 j _,/_,.,),-/ DYESDNO
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<br />16. FED.ERA.'t.EVI~i!-~it:u'e'Agenc~:da;el ;; I FEMA REVIEW /lnitia/sanddate)
<br /> / f:f:"c, "'" '.,~ [./:1 ;1, /'1ftt- I
<br /> I
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<br />FEMA Form 90-52, JAN 81(Formerly HUD Form 4841
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