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<br />FEDERAL EMERGENCY MANAGEMENT AGENCY
<br />DAMAGE SURVEY REPORT
<br />DISASTER RESPONSE ANO RECOVERY
<br />(See instructions on reverse)
<br />
<br />
<br />01\18 No. 3067-0027
<br />3. DECLARATION NO.
<br />FEMA / -LJt<:'-('o
<br />4, INSPECTION D^TE
<br />
<br />
<br />1. TO'" REGION...1!!3 FEDERAL EMERGENCY MANAGEMENT AGENCY
<br />
<br />2. APPLICANT (St3te Agency, County, City, etc:.J /KIrJTr .) ; PA NO.
<br />frlUlH1U"'T ~~ a.u> ~ a,..,,ury' __ I/Q7-13i'aS-
<br />7. WORK CATEGORY (aX" Applicable Box) I DSR NO.
<br />IJ'\ EMERGENCY I)(! A DB I
<br />IT.] D PERMANENV tJ' C D 0 D E D F D G D H D ,: 2 4 7 1 4
<br />
<br />8. DAMAG ED F ACI L1TJ ES (LoCiltio,n, idrmtification and d8SCription~,
<br />PRIf/ill-17! ~/4E.;f/CE "'NO 4me.ee'N ~A!t b~LZ-.e
<br />o,c" 11/" ~ ~MeK
<br />
<br />5. WO" ACCOMPLISHED BY
<br />
<br />~ONTRACT
<br />D FORCE ACCOUNT
<br />
<br />6. PERCENTAGE OF WORK
<br />COMPLETED TD DATE
<br />[}]
<br />BA. .fACILITY.l1\I OR,AFFECTS
<br />FLOOO PLAIN.DR WET LANDS
<br />
<br />%
<br />
<br />~YES
<br />
<br />DNO
<br />
<br />9. DESCRIPTION OF DAMAGE
<br />
<br />Re-p!pve ~~(.ICT""/bN- ~p ~e:./.d~r-;,I.~ I ,()IY~ ~n::;.#e',e
<br />/ov,,,,,e ,C!.ek., 77I-eeHrJUf//lf/4/...e,v"r.e; k:5dJe:;,</C.~ 4NO rv8L1c ~FS
<br />1lIe.-.A: Co~~e4 CP Nre:.t- r ,,(A.eJ""~'" Sr:>.
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<br />.~~
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<br />t:/ttlNNeL
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<br />10. SCOPE Of PROPOSED WORK
<br />A"'"~6'lAl'" (!)"'nepc1;'lc~
<br />,
<br />"
<br />,-
<br />
<br />1?54 4'~~d4.
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<br />of
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<br />
<br />QUANTITY -----uNITl
<br />{al lbl
<br />
<br />
<br />11, ESTIMATED COST OF PROPOSED WORK
<br />T
<br />MATERIAL ANDIOR DESCRIPTION
<br />lei
<br />
<br />COST (dol/an)
<br />'(eJ
<br />
<br />~.;~, :;"^,,
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<br />----L
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<br />15,
<br />
<br />
<br />0TOTAL" $ :225"
<br />
<br />'ELIGlSLE--dD-- ATTACHMENTS
<br />[J YES' NO
<br />CONCUR
<br />DYES [yNO
<br />RT B LOCAL REPRESENTAT VE (Signature, AgenCY~ ~ I. CONCUR
<br />e 7JP,4. YES D NO
<br />J F A RE""'VIf!:ii7'nJtlals Ojnd date)
<br />
<br />; AMOUNT
<br />,$ -0-
<br />
<br />12, EXISTING INSURANCE IType!
<br />.N~~_
<br />RECOMMENDATION BY FEDERAL I
<br />~
<br />
<br />13.
<br />o
<br />
<br />14_
<br />
<br />ATTACHMENTS
<br />
<br />ATTACHMENTS
<br />
<br />16,
<br />
<br />FEMA Form 90-52, JAN 81(Formerly HUO Form 484)
<br />
<br />
<br />. ; :..: ~.~ i ( -' . .:
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