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<br />DYES l;(NO l <br /> <br />...,....",,,>1 "....."" i (",._ 40- 4t~....< t:' ~C.I')I": <br />oOt50 .l.O' h."""j,c,,1e.//y ~~J/~ <br /> <br />I <br />~ <br /> <br />L~____:=:..:. <br /> <br />FEDERAL EMERGENCY MANAGEMENT AGENCY <br /> <br />DAMAGE SURVEY REPORT <br /> <br />DISASTER RESPONSE AND RECOVERY <br />(See instructions on reverse) <br /> <br />,. TO" <br /> <br />REGION ..Iii...- FEOERAL EMERGENCY MANAGEMENT AGENCY <br />-. -.,. <br /> <br />2. APPLICANT (Stare Agency, County. City. etc.) <br /> <br />~,u",ly d.l.~fr <br />7. WORK CAT€GORY ("X Applicable Box) <br />C EMERGENCY 0 A 0 B <br />CD C:;;( PERMANENT Q C CD 0 E D F D G "H 0 I <br /> <br />8. DAMAGED FACILITIES (Location, identification and descn"ption) <br /> <br />/?o.d fit/lr L'/l hl~ Ilru,~ K.Jl~ JJ,..!J <br /> <br />; PI-\ [\11]. <br />'--Lv. -/) Db tJ[) <br />I OSR NO. <br />, <br /> <br />24983 <br /> <br />AI"~ "",e/<p,1 <br />9. DESCRIPTION OF DAMAGE <br /> <br />}11""",. l""'u"'~, <br /> <br />4 4(0,,1 ...st'ell''''^- <br />5......... f'/_rL'~ , <br /> <br />/..1 /"''''"''1 ~..c'f~",~,';'~ /i&.,J <br /> <br />v t r'" Q J {".) .5 lt6'f t ~~ ~ '-, '" .,( <br />I vcv/!r".//y. <br /> <br />10. SCOPE OF PROPOSED WORK R <br />Cr......,1)-'"l("Ir',-r."."'"' 4)....4 II'" <br /> <br />(1,<: R/.... <br /> <br />0,\113 No. 3067-0027 <br />3. DECLARATION NO. <br />FEMA7/90".ro <br />4. INSPECTION DATE <br />- /0 - a fI. <br />5. WORK ACCOMPLISHED BY <br /> <br />o CONTRACT <br />I G( FORCE ACCOUNT <br /> <br />ts. PERCENTAGE OF WORK <br />I ~ COMPLETED TO DATE <br /> <br />IT! /00 % <br />8A. FACILITY IN OR AFFECTS <br />FLOOO PLAIN OR WET LANDS <br /> <br />UNIT <br />Ibl <br /> <br />11. ESTIMATEO COST OF PROPOSE[) WORK <br />MATERIAL AND/OR OESCfllPTION l-'Zi~;:;:'P~I~E' <br />~ ~ <br /> <br />COST (dollars) <br />(el <br /> <br />~2._E_XISTIN~=NCEfTYpe) .. ....n___: ;M~~~T _ n..__ciJ-TOT~[:~nSn_ <br /> <br />13. RECOMMENDATIONBY FEDERALINSPECTOR (Signatur~', Agencv, datu) ~ ELIGIBLE @] <br /> <br />~ __.______ /t-/W-1-- .'''-<1- t'7. tQvEsDNO <br />I RT BY STATE INSpmOR (Signature. Agency, date) :}CONCUR <br /> <br />15. CUR~?;C" ~E p' Y LOCAL REP~';E:;~~~L<t_.. .~~~~:: <br />~'~'flr:::'!5f9J{,:J'e,4.J-nii: J::e) . - -;, ,c:I', FEMA rfiVitw-'7i;;;;;a/s nd dare)-- <br />I \ ~_~____._ <br /> <br />QUANTITY <br />101 <br /> <br /> <br />1:3- <br /> <br /> <br />/ <br /> <br />)70 ;:I <br />ATTACHMENTS <br /> <br />A <br /> <br /> <br />TS <br /> <br />ATTACHMENTS <br />