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<br />~ <br /> <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$tOJreAfX!.ncy, County, City, ete.) ; PA NO. <br />. 0", Ie.. Ctp4>,k.. I /07- <br />7. WORK CATEGORY f"X" Applicable Box) i o'SR NO. 6. PERCENTAGE OF WORK <br />o EMERGENCY 0 A 0 B : COMPLETED TO DATE <br />CD 0 PERMANENT 0 COD 0 E CKI FOG 0 H 0 I I 2 4 5 [) 2 IT! Q % <br />a. DAl\,lAGED FACILITIES (Location, identification and dacriptionJ. - / tfJ SA. FACILITY IN OR AFFECTS <br />t<~ lA.J19-/--..r :5"""'f/'" ,...,~=--VO' r-: Lcc..?-___~)l FLOODPLAIN OR WET LANDS <br />9,a?//....~ 40'-- ~'~..v /-"" OA f Cr",,'€ ~;1'7y, r""'. [)( YES 0 NO <br />., _#nr:/:,cC /)/d,/2 - ("~~ ~Jt ;:) <br />9. OESCRIPTIOI<CZOAMAGE .~-tf- / 't/t/ .f ---5 ~o/r- .7 ""'" / ,./ <br />...J / ......"..('eL~'~'?//:s~~.rv /......"',,-v . ~r- ~ fOr ?(;, c.rr- <br />,rr...e €>f' "'-'~. '-<.).<'/71-14(/F'>.... ilG/<-~", 7. 4./.., ",. b /"""....:. /.,...._5. <br />,j)/tPJ-eJ 6y ~,/r ,I....-+.vOS/,.. j)/ovk-dJ 77t... ,..y;S,.,Z/W5' fir-",- <br /> <br />;.. ~V fi{" d;nw. <br /> <br />~CONTRACT <br />o FORCE ACCOUNT <br /> <br /> <br />10. SCOPEOfPROpOSEOWORK r S ',"'J", '~ '/.V<I <br />I...- /,,,.. 6 t rYfI,,,,,vj _ ~ .4)'5 ~.....- '$~ . '... ~;;/>'"'''' 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~- /'$-""/,....;) f"wV/J",. <br />A-rv ~~ffJ {. 6n--r.f~ W' tt... 01 I? .l>,P M/~ 7"'f.. 7k.nr...w fa <br />5'I(-Jwl"'-f.-;- ~""f/..Jt /lrK ..; 4. a 1G.'f),,.,, .6y?~~5 ,,;,., to'....~ n-r,,--,s ~d1. <br />/ 11. ESTIMATED COST OF PROPOSED WORK <br />-- --~--~-- <br />MATERIAL AND/OR DESCRIPTION <br />leI <br /> <br />OUANTITy-'UNiT-T .- <br />{al II>I <br /> <br /> <br />UNIT PRICE <br />Idl <br /> <br />COST (dollars) <br />leI <br /> <br />iA>; <br /> <br /> <br />( <br />, <br /> <br />./)>';""""1 <br /> <br />:tf <br /> <br />,~ - <br /> <br />, <br /> <br />L.n <br /> <br />.1/>. <br /> <br />20- <br /> <br />i <br /> <br />~,:... <br /> <br />4.7' <br /> <br />I ~.J...-;;:;,...., "'.........yf ~~, <br />/. f <br /> <br /> <br />'lo.~ <br />/47~ <br />. "' <br /> <br /> <br />#....;. <br />fin" r."",... ~ Is --J. 9l :2 <br />~.I..,<./ 7 <br /> <br /> <br />~---- -- .---,~_. <br /> <br /> <br />'<' <br />CONCURRENCE IN REPORT Y STATE IN PE <br /> <br />';;' <br /> <br />uuJ~:~: ;57;'73-- <br /> <br />I ELIGIBLE @] <br />sO NO <br />CONCUR <br />DYES 0 NO <br />CONCUR <br />DYESDNO <br /> <br /> <br />A ACHMENTS <br />/-2 ~ Z>-!>d: <br />ATTACH NTS <br /> <br />'2. EXISTING INSURANCE (Type) <br /> <br />; AMOUNT <br />,$ <br /> <br />15. CONCURRENCE IN REPORT BY LOCAL REPRESENT-ATIVE-Ts;g-;;;;r~~;;,-Ag;ncy, daleT-----~-- <br /> <br />ATTACHMENTS <br /> <br />16. FEDERAL REVIEW (Signature, Agency. date) <br /> <br />- 'f-FEMA -R'EVIEw ,initials and date} <br />I <br />I <br /> <br />FEMA Form 90-52, JAN 81(Formerfy HUD Form 484) <br />