|
<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 />
|