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<br />
<br />OMS No. 3067-0027
<br />3. DECLARATION NO.
<br />FEMA
<br />
<br />FEDERAL EMERGENCY MANAGEMENT AGENCY
<br />
<br />DAMAGE SURVEY REPORT
<br />
<br />DISASTER RESPONSE AND RECOVERY
<br />(See instructions on reverse)
<br />
<br />2. APPLICANT (StilteAgency, County, City, ete.)
<br />('n-.rl"7"' ~)
<br />
<br />; PA NO.
<br />I //}:J _ A ?.Il.-.1 (/
<br />: DSR NO.
<br />
<br />I 24706
<br />
<br />
<br />4.
<br />
<br />" TO" REGION
<br />
<br />-J? FEDERAL EMERGENCY MANAGEMENT AGENCY
<br />
<br />7. WORK CATEGORY (nX" Applicable Box)
<br />o EMERGENCY 0 A 0 B
<br />Q] PERMANENT 0 COD 0 E 0 FOG 0 H ~ I
<br />
<br />8. DAMAGED FACI LlTI ES (Location. identificstion and dsscrjptionj
<br />
<br />~.eL SE/'I /flU. 0</ CO~P(;..E~
<br />
<br />sn:~_q.,4r S........e.r~S
<br />
<br />6. PERCENTAGE OF WORK
<br />COMPLETED TO DATE
<br />
<br />o c:J%
<br />
<br />SA. FACILITY lNORAFFECTS
<br />FLOOD PLAIN OR WET LANDS
<br />
<br />DYES
<br />
<br />~NO
<br />
<br />9. DESCRIPTION OF DAMAGE
<br />'-I9NOS<-/Pc /VedA!? 70 47cnr;e -SA'" .7<;;,rt,/-, XM:X!"'Gd ""<XV...... --9 ,<:b"""" 7?J~.:R
<br />(,(,frr RoPe suPJ"aer Tt:uuER) PE..r7R<JYEO A $</t?4J -"nA",,//v~ '
<br />~€' ~~.tm_,r ~,... n"',~ --~-"n_ ,...., /?7-'TCH/Ah:
<br />r'E6I/sr/U. / CJt:STeo C/ r. -, ,---~ ~ ~~~~~W~~~r_..... ELeaT.e/CA'- AA.-o
<br />
<br />e '47A1VNleAT;CJ/V ~/Nes-.
<br />10, SCOPEPfFROPOSEDWPRK , . .' ,
<br />~,JE:r- 77"c ~_..... T.xvc~ A!'e#>9~ T~ ,L./pr..eol"'C; ~.vO "c5er ';"m;;NOlnHe
<br />
<br />;f/II'GrYe-,,,,,,,~AT/O~ .~,,: .7H~"f"'P~-'<. .R~"'~~ee ~_w _,,9.<<.iN(; G'~.41
<br />
<br />I'*TQ/~' 2'.e;~,:~;~~/ ~{Vo~L'''~",,~<:J. CO__"'~_"~#T:i",,,,,..~,~e,,
<br />
<br />1'1/110 I:lW"':rv~1F~~QV"';Q. ,'i:i.I~?:~C4'~;vc,.. ~,..... ">~.
<br />
<br />QUANTITY
<br />{al
<br />
<br />
<br />11. ESTIMATED COST OF PROPOSE
<br />MATERIAL AND/OR DESCRIPTION
<br />(el
<br />
<br />".>
<br />
<br />'~./
<br />
<br />
<br />12.
<br />
<br />13.
<br />~
<br />14.
<br />
<br />ATTACHMENTS
<br />
<br />ATTACHMENTS
<br />
<br />15,
<br />
<br />ATTACHMENTS
<br />
<br />16,
<br />
<br />:<
<br />
<br />: " :_ C~ ! ':)
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