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<br />FEDERAL EMERGENCY MANAGEMENT AGENCY
<br />
<br />DAMAGE SURVEY REPORT
<br />
<br />DISASTER RESPONSE AND RECOVERY
<br />(See instructions on reverse)
<br />
<br />OMti f\lo. 3067-u027
<br />
<br />1. TO'"
<br />
<br />REGION
<br />
<br />8
<br />
<br />FEOERAL EMERGENCY MANAGEMENT AGENCY
<br />
<br />3. DECLARATION NO.
<br />FEMA 7' ') 0/<
<br />4, IN~PECTION D^TE
<br />8,1'1- ~
<br />5. WORK ACCOMPLISHED BY
<br />
<br />. 6,0, _
<br />
<br />- '//;-.:.. ,/1'-'.' .
<br />-~-f--L--=----"'-~~.._--
<br />DSR NO.
<br />
<br />o CONTRACT
<br />[)( FORCE ACCOUNT
<br />
<br />2. APPLICANT ($t:Jre Agencv, C;'-untV, City, ere.!
<br />
<br />it,-5>.i......b-.I<.1...-0DJ.,S'" ,..,~~.s
<br />7. WORK CATEGORY ("XU Applicable Box) ,
<br />[j;j EM[RGENCY l:;(l A 0 B
<br />IT] C PERMANENT 0 COD 0 E [J F C G [','] H 0 I
<br />8. DAIV1AGEO FACI L1TIES (Location, identification and descriptionJ
<br />tJ" ".,.......~~ dl.r1"V'...""", -r. K Mt,j......A'';,
<br />f ~ ,. I
<br />...... 1A'.". t. aAi 4; ~ .... e;I pll'" . A C. (0"R W fU ~
<br />
<br />'" Y'D"yJof ,i,~p t~y.....~, 3,!Jh'Z;/o~y
<br />
<br />9. DESCRIPTION OF DAMAGE ;11" '" rD (k.> '" ",I d, " ,/$ ./ I'. ..... ~ oJ ..... 1'~
<br />
<br />;+f,,,,j- i"If,,,.e,.v /t>r,.7rc.....S (It,...., c.o&-(",..c s~',^..I,,,,.
<br />i 1.,.g
<br />
<br />. PA NO.
<br />
<br />24~98
<br />
<br />6. PERCENTAGE OF WORK
<br />COMPLETED TO DA TE
<br />(lJ
<br />SA.
<br />
<br />/00 %
<br />FACILITY IN OR AFFECTS
<br />FLOOD PLAIN OR WET LANDS
<br />
<br />ft#"""'"'''' o;t,.!r,YI'"
<br />.... At',1 rJ-..C'.t ",...,..,A
<br />
<br />DYES
<br />
<br />CXNO
<br />
<br />,.,
<br />
<br />....." 4o..J
<br />
<br />.......:-y.
<br />
<br />I,. <-'/..1,,/,, -,. 7.
<br />PM,(J,';- Z.t,).,?
<br />. "
<br />
<br />~ /'
<br />
<br />5/U,."
<br />
<br />..r
<br />
<br />10, SCOPE OF PROPOSED WORK ~ I. ' k ,/ ,
<br />ll..1'~~t''' """A'"I~'~6Z-'~'''' ,........'"'-0....' rJ.... ,.,,,~ y., .$.~#Mnt!.~/'.J
<br />, T -~ ...I. &-1 .... Ii .(,
<br />f/'",... [l-1-t ""'.Cl.t. 4.v1t~"l'pc.ss..4r/"'f.........r~,,'r,;.t, (J.., '\o',(T~- p~..r'_:".)
<br />
<br />,CjIIJAL DS'{J
<br />
<br />QUANTITY
<br />lal
<br />
<br />UNIT --r-
<br />Ib)
<br />
<br />11. ESTIMATED COST OF PROPOSED WORK
<br />MATERIAL AND/OR DESCRIPTION
<br />Ie)
<br />
<br />UNIT PRICE
<br />(d)
<br />
<br />COST (dollars)
<br />Ie}
<br />
<br />
<br />'~-; II: t:J 4
<br />
<br />(.,0
<br />
<br />; "..:: ',-
<br />
<br />.,.-"
<br />
<br />
<br />12. EXISTING INSURANCE (Type)
<br />_._____,,#"_."U'___ .u _ __ _ _ _.. ~,____
<br />13. RECOMMENOATIO BY FEDERAL INSPECTOR rSicln.iturl!, Agency, da[(')
<br />o
<br />
<br />; AMOUNT-
<br />I $
<br />
<br />,5"(,0
<br />
<br />'4.
<br />
<br />ATTACHMENTS
<br />:sA/..s
<br />ATTACHMENTS
<br />
<br />15.
<br />
<br />ATTACHMENTS
<br />
<br />16,
<br />
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