<br />2. ,APPLICANT (StateAgeno/~ County~ City~ ete.)
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<br />7. WORK CATEGORY ("XU Applicable Box)
<br />c;;kEMERGENCY Q A 0 B
<br />OJ 0 PERMANENT 0 COD 0 E 0 FOG 0 H 0 I
<br />
<br />8._ DAMAGED-FACILITIES (Location, identification and description}
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<br />; PA NO,
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<br />I DSR NO,
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<br />OMB No. 3067-0027
<br />3. DECLARATION NO.
<br />FEMA 7" .-<: C 0
<br />4, INSPECTION DATE
<br />6". ,- ~
<br />5. WORK ACCOMPLISHED BY
<br />
<br />o CONTRACT
<br />!;ll;.FDRCEACCOlJNT
<br />
<br />FEDERAL EMERGENCY MANAGEMENT AGENCY
<br />DAMAGE SURVEY REPORT
<br />DISASTER RESPONSE AND RECOVERY
<br />(See instructions on reverse)
<br />
<br />1, TO" REGION_9_ FEDERAL EME6GENCY MANAGEMENT AGENCY
<br />
<br />24415
<br />
<br />6. PERCENTAGE OF WORK
<br />COMPLETED TO DATE
<br />o
<br />
<br />%
<br />FACILITY IN OR AFFECTS
<br />FLOOD PLAIN OR WET LANDS
<br />
<br />Ar~ ~ OS ~ R-..(
<br />
<br />BA.
<br />
<br />[J YES
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<br />
<br />9. DESCRIPTION OF DAMAGE
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<br />114L"Ct'S$ ,.....~d
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<br />10. SCOPE OF PROPOSED WORK 'f?,;':"'~';;i";"';,{;.t w """'7
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<br />
<br />11-
<br />MATERIAL AND/OR DESCRIPTION
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<br />
<br />
<br />14.
<br />
<br />[2] TOTAL'" $
<br />
<br />ELIGIBLE @]
<br />2;. n _ 81 Q.-\'ES 0 NO
<br />CONCUR
<br />YES 0 NO
<br />CD CUR
<br />OYESONO
<br />
<br />/
<br />/e; ., 0
<br />ATTACHMENTS
<br />
<br />ATTACHMENTS
<br />
<br />/5.
<br />
<br />ATTACHMENTS
<br />
<br />16.
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