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<br />
<br />OMS No. 3067.0027
<br />3. DECLARATION NO.
<br />FEMA
<br />
<br />FEDERAL EMERGENCY MANAGEMENT AGENCY
<br />
<br />DAMAGE SURVEY REPORT
<br />
<br />DISASTER RESPDNSE AND RECDVERY
<br />(See instructions on reverse)
<br />
<br />
<br />1. TO'" REGION_-8-- FEDERAL EMERGENCY MANAGEMENT AGENCY
<br />--2. APPLICANT (State Agency, County, City, ere.) ; PA NO.
<br />-C"'tJ, J.., I .")<'11, I1Y/)
<br />"X" Applicable at, J : DSA NO.
<br />A DB I
<br />IT] 0 PERMANENT COD 0 E 0 FOG 0 H 0 I I
<br />8. DAMAGED FACtLITIES -fL,!CBtion, identif{cation and d9lC1iption), ~
<br />c"~('k 1?J'$ arro,(. S 1M", E. 0/ sfl s1;1.
<br />
<br />~5d. ;'Aqp r]) oR-S-
<br />9. DESCRI!tn6N O~ DAMAGE -.-, I. /' I .H f
<br />IOVO """'J (I"" s, at: ~ ",,.,,
<br />7~' ~{ ~Oq"Jv.J'1 ~ tg":-3Z' eM? 1: to
<br />t1ot' loA dW.I"'tl1~ 4VC4 ~ .u.s ,../of.....
<br />hDV,'Z.',. IS' .())vf .
<br />10. SC.OP~.OF P ,POSED WORK 'CltiIfA"ibiJ'f.,$//J'-c ,."d~.,," ( ; ,;" '$10114J.II~l CMP a ~ ,
<br />
<br />;H, I'JoJID",~{.IIC."~t'~~l;~If:'L~.,k"urrl-, .,1~~~{$~.~L".. ~'.l/e7~fI~f. A
<br />
<br />~J&40'" ....-10 ........tt.;:~~~f~.,;.{~. ?.;!R?J,i.,. ......1. '~,~/p. 'e~t(:tilf tiS'" :'-s<<'~f'{i'(J"I:II' tr:.
<br />s;-/".s .:12t:~l Tt";~'CI))fi><,;.,i19@"'S;l:d'''/fr'' . ". . '.,
<br />
<br />o CONTRACT
<br />~FORCE ACCOUNT
<br />
<br />
<br />24845
<br />~J. . t ., tAd/
<br />See. +,~.. 4 J
<br />
<br />6. PERCENTAGE OF WORK
<br />COMPLETED TO DATE
<br />o
<br />
<br />%
<br />BA.!'ACILrry,IN OR AFFECTS
<br />FLOOOP/.AINOR ylET LANDS
<br />
<br />
<br />9(:NO
<br />
<br />c1~~~.Jecl o"O~cJ. 5i!" I IUdVed,
<br />IZS1 ripw..J..,II. 5.1". ~ t.lJQ~
<br />ge' tJ ( fI'(ltulWa'f MIJlleJ A!i I
<br />
<br />DYES
<br />
<br />qUANTITY
<br />'.1
<br />
<br />
<br />11. ESTIMATED COST OF PROPOSED WORK
<br />MATERIAL ANDIOR DESCRIPTION
<br />
<br />COST (dollars)
<br />
<br />~
<br />Suh-lo&l
<br />
<br />
<br />*
<br />
<br />
<br />~.~ -#"~
<br />I AMOUNT
<br />1$
<br />
<br />12. EXISTING INSURANCE (Tvpe)
<br />
<br />-~-~-~_. --------
<br />L I NSPECTOR (Signature, Agency, date)
<br />. r-:.Jrllt:1 ~ ID~
<br />EcrOrltti~.Age"CY,date} .
<br />
<br />ATTACHMENTS
<br />
<br />r:c:"
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