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<br />2. ,APPLICANT (StateAgeno/~ County~ City~ ete.) <br /> <br />.....f", t k , l... 1".0<1 .. I y <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} <br />Co;-' sol,,,,/.,..,l f~it~f..1,:,,,,, Ot"3Tp/."r <br /> <br />,,,..J. 4... r//';', f"",J/. <br /> <br />; PA NO, <br />I t17-0000Q <br />I DSR NO, <br />I <br />I <br />I <br /> <br />I "ill\ "iJPlvv,;u <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 <br /> <br />~o <br /> <br />9. DESCRIPTION OF DAMAGE <br /> <br />~I P t.. <br /> <br />,,' .,I" p <br /> <br />*. <br /> <br />M",,( ~ hi.'... <br />..(. 4" 0 ".; of. <br /> <br />.,,)O-,~ ,A1vpo,r <br />:1< fl..,-I,;"y p,~d <br /> <br />e.o <br /> <br />P,s"" ~o",'y.l <br /> <br />114L"Ct'S$ ,.....~d <br /> <br />10. SCOPE OF PROPOSED WORK 'f?,;':"'~';;i";"';,{;.t w """'7 <br /> <br />C6" -~.",.<1.",...' t.~'1t.l"" M';'~'"-#f;"~~r. <br /> <br />"-~ <br /> <br /> <br />.. FI4<~ It".., <br />)'h .".1<, <br />"';J <br />, <br /> <br />{)t;('$Iw~'~...j{te..,.\'n9'''' 'l"e"",:".,,-I .'~ <br /> <br />'"!- 3.>,:;'-' <br /> <br />11- <br />MATERIAL AND/OR DESCRIPTION <br /> <br />=t <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. <br /> <br />FE <br /> <br />t j 10"/ ., . f- i r _.~ ,-~; r: r (' <br />