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<br />011..18 No. :.WG7-Q027
<br />3. DECLARATION NO.
<br />FEMA _
<br />
<br />FEDERAL EMERGENCY MANAGEMENT AGENCY
<br />DAMAGE SURVEY REPORT
<br />DISASTER RESPONSE AND RECOVERY
<br />(See instructions on reverse)
<br />
<br />,. TO" REGION_. e
<br />
<br />FEDERAL EMERGENCY MANAGEMENT AGENCY
<br />
<br />
<br />2. APPLICANT f$tOJreAfX!.ncy, County, City, ete.) ; PA NO.
<br />. 0", Ie.. Ctp4>,k.. I /07-
<br />7. WORK CATEGORY f"X" Applicable Box) i o'SR NO. 6. PERCENTAGE OF WORK
<br />o EMERGENCY 0 A 0 B : COMPLETED TO DATE
<br />CD 0 PERMANENT 0 COD 0 E CKI FOG 0 H 0 I I 2 4 5 [) 2 IT! Q %
<br />a. DAl\,lAGED FACILITIES (Location, identification and dacriptionJ. - / tfJ SA. FACILITY IN OR AFFECTS
<br />t<~ lA.J19-/--..r :5"""'f/'" ,...,~=--VO' r-: Lcc..?-___~)l FLOODPLAIN OR WET LANDS
<br />9,a?//....~ 40'-- ~'~..v /-"" OA f Cr",,'€ ~;1'7y, r""'. [)( YES 0 NO
<br />., _#nr:/:,cC /)/d,/2 - ("~~ ~Jt ;:)
<br />9. OESCRIPTIOI<CZOAMAGE .~-tf- / 't/t/ .f ---5 ~o/r- .7 ""'" / ,./
<br />...J / ......"..('eL~'~'?//:s~~.rv /......"',,-v . ~r- ~ fOr ?(;, c.rr-
<br />,rr...e €>f' "'-'~. '-<.).<'/71-14(/F'>.... ilG/<-~", 7. 4./.., ",. b /"""....:. /.,...._5.
<br />,j)/tPJ-eJ 6y ~,/r ,I....-+.vOS/,.. j)/ovk-dJ 77t... ,..y;S,.,Z/W5' fir-",-
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<br />;.. ~V fi{" d;nw.
<br />
<br />~CONTRACT
<br />o FORCE ACCOUNT
<br />
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<br />10. SCOPEOfPROpOSEOWORK r S ',"'J", '~ '/.V<I
<br />I...- /,,,.. 6 t rYfI,,,,,vj _ ~ .4)'5 ~.....- '$~ . '... ~;;/>'"'''' P<'15~;
<br />I a/,it.,/~ #~..i,,y"'r5./'N!I :5.t...:...c~.. ..... ~""o,-~h--4'_. ' "".' _ . J . ~/
<br />. ./1 "'~-, L>,p~slr~"~'iP t;:".:;,.., . ttff"".."........... S;J.y...€.~ (?"'~
<br />;ill~,.,y &-(7. 1.~,(L.U1.(!1 (!1"",:Ff' tk 4!tNr4r-/"-f ~.. .'.r<r~- /'$-""/,....;) f"wV/J",.
<br />A-rv ~~ffJ {. 6n--r.f~ W' tt... 01 I? .l>,P M/~ 7"'f.. 7k.nr...w fa
<br />5'I(-Jwl"'-f.-;- ~""f/..Jt /lrK ..; 4. a 1G.'f),,.,, .6y?~~5 ,,;,., to'....~ n-r,,--,s ~d1.
<br />/ 11. ESTIMATED COST OF PROPOSED WORK
<br />-- --~--~--
<br />MATERIAL AND/OR DESCRIPTION
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<br />OUANTITy-'UNiT-T .-
<br />{al II>I
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<br />UNIT PRICE
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<br />COST (dollars)
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<br />~---- -- .---,~_.
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<br />CONCURRENCE IN REPORT Y STATE IN PE
<br />
<br />';;'
<br />
<br />uuJ~:~: ;57;'73--
<br />
<br />I ELIGIBLE @]
<br />sO NO
<br />CONCUR
<br />DYES 0 NO
<br />CONCUR
<br />DYESDNO
<br />
<br />
<br />A ACHMENTS
<br />/-2 ~ Z>-!>d:
<br />ATTACH NTS
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<br />'2. EXISTING INSURANCE (Type)
<br />
<br />; AMOUNT
<br />,$
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<br />15. CONCURRENCE IN REPORT BY LOCAL REPRESENT-ATIVE-Ts;g-;;;;r~~;;,-Ag;ncy, daleT-----~--
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<br />ATTACHMENTS
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<br />16. FEDERAL REVIEW (Signature, Agency. date)
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<br />- 'f-FEMA -R'EVIEw ,initials and date}
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<br />FEMA Form 90-52, JAN 81(Formerfy HUD Form 484)
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