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<br />DECLARATION NO.
<br />FEMA 71:J tJ K - C U
<br />4, INSPECTION DI'.TE
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<br />....... ' ~ 5, WORK ACCOMPLISHED BY
<br />1. TO..,.. REGION _ [; FEDERAL EMERGENCY~NAGEMENT AGENCY
<br />___..~_._..-'----u--~' _~_. ____'.._ .,.______'_ __ __,_._ 0 CONTRACT
<br />2. APPLICANT (Sc:JceAgency, County, City, etc.) \ ; PA NO. Q FORCE ACCOUNT
<br />.,_ L9J-/ tLf. Y~.J:>.1_~~_tI____'-,...______~ jj).).-JJ15lJITt)_
<br />7. WOHK CATEGORY '''X'' Applicabh' Box) \ 'DSR NO 6. PERCENTA.GE OF WORK
<br />r;;;.< EMERGENCY n A C B I COMPLETED TO DATE
<br />7'" ~ ,.., 4 (-, {" ('
<br />OJ r'J PERMANENT Dc [JD I:=JE ':=JF DG,DH :'::::1 {' J('o ill /00 %
<br />8. DAlv1AGED FACILITIES (LocatJ"on. idehtification and~cription) 8A. FACtLlTY IN OR AFFECTS----I\
<br />R.6e.~ fL.!) tj.",..,i S",,1J. 0-1 fA:., $"..A-< ~'f.v'" 13",.,,)f'C I FLOOD PlAIN OR WET LANDS
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<br />9. DESCRIPTIONOFDAMAGA ItA ,,-;--;I.-.:--r:~,y..--:-::::-r. vi ',,)--'I;~"" y ,,...1 /.~ ~O. ,--'/'"
<br />[I" ",,"'...{ r" co -'r rll- ,,+ t.;-' to 1'-' 'r/-'f', f r .,.,.( (.,r" "_.L fl.,~f'~
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<br />FEOERAL EMERGENCY MANAGEMENT AGENCY
<br />
<br />/-,
<br />13
<br />
<br />OMS No, 3067-0027
<br />
<br />DAMAGE SURVEY REPORT
<br />
<br />DISASTER RESPONsE AND RECOVERY
<br />(Sce instrucrions on reverse)
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<br />10. SCOPE OF PRQPOSEDWORK 0
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<br />rJ.#'~~ $" ""'" 41 If!'.
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<br />QUANTITY
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<br />UNIT
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<br />11. ESTIMATED COST OF PROPOSED WORK
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<br />UNIT PRICE
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<br />COST (dollars)
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<br />12~ EXISTIN~:U::CEI~ype) _ ~___-~j~~OUNT., _j Gr~~A~~;_ __ /~ / L
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<br />'~. RECOMMENDATION BY FEDERAL INSPECTOR (S"",,,",,', A"",c, dare) , 1 ELIGIBLE rn ATTA-CHMENTS
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<br />14. ~U:-~~E:O~TATE INSPECTOR IS'goaMe, Agency, dare} CONCUR
<br />_ _- _ ___doll . _3'-/~-z.4- ___.W:r'ESONO---
<br />15. ONe ~RR NeE IN REPOR BY LOCAL REPRESENTATIVE rS/9narure,Agencv,dareJ CONCUR ATTACHMENTS
<br />[:iJVr<<<-~- ._~r~ - q ~.Lo~'i'.!L ~EsD NO
<br />16, EDt'RA, R W, n ~<e.AgencY,date} ;:;; .~~-;-- :FEM'A'REVIEW Omr;al,.nddareJ
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