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<br />./ <br /> <br />mils No. 3067-0027 <br />3. DECLARATION NO. <br />FEMA <br /> <br />4. INSPECTION DATE <br /> <br /> <br />FEDE:RAL EMER .ICY MANAGEMENT AGENCY <br /> <br />DAMAGE SURVEY REPORT <br /> <br />DISASTER RESPONSE AND RECOVERy <br />(See instructions on reverse) <br /> <br /> <br /> <br /> <br />1, TO'" REGION '7? <br /> <br />FEDERAL EMERGENCY MANAGEMENT AGENCY <br /> <br />2. APPLICANT (State Agency, County, City. ere.) <br /> <br />.c <br />7. WORK CATEGORY ("X" Appficable Box) <br />1iit EMERG ENCY 0 A liC:.s <br />IT] 0 PERMANENT 0 COD 0 E 0 FOG 0 H 0 I <br /> <br />U7G692 <br /> <br />6. PERCENTAGE OF WORK <br />COMPLETED TO DATE <br /> <br />IT! 0 % <br /> <br />SA. FACILlTy'IN OR AFFECTS <br />FLOOD PLAIN OR WET LANDS <br /> <br />8. DAMAGED FACILITIES (Location, identification and description} <br />FILL 4A1{/ R/PRIIP OF' I-1/600AJ €1118ANk/11€AJT /if)JAC€NT TO <br />()NComPAHGR~ I{/V€~. I)J~-;T 51P€ of .l-AGOOAl!;. ,;l. f' 3, <br /> <br />DYES ";)iC!'NO <br /> <br />9. DESCRIPTION OF DAMAGE <br /> <br />GROS/ON OF WEST Btll,Jl< <br />UtJComPAHGRe R,,/'i:~. <br /> <br />OF J..Ar..oo#5 ;J..r3" <br /> <br />13-( <br /> <br />, <br /> <br />10. SCOPE OF PROPOSED WORK <br /> <br />, <br /> <br />riLL + R/PI?IlP 35"00 FffT <br />~I VEl? <br /> <br />or eP113AAlKIflfCPT 1}J.f)AlG U~CO/flPIIIIGRe <br />./' ,., <br /> <br />QUANTITY <br />1.1 <br /> <br />UNIT <br />Ibl <br /> <br />11. ESTIMATED COST OF PROPOSED WORK <br />MATERIAL AND/OR DESCRIPTION <br />lei <br /> <br /> <br />COST (dollars) <br />(el <br /> <br /> <br />~ <br /> <br />~ <br /> <br /> <br />f, <br /> <br /> <br /> <br />I <br />''1 <br /> <br />12. EXISTING INSURANCE (Type) ; AMOUNT .. .~ <br />,$ MA" [2] T(:~_ $ 13/-"-/q7. 00_ J <br />OM ENOAT10N BY EDERAL INSPECTOR (Signature, Agency, dateJ ELIGIBLE [[l ATTACHMENTS I <br />~/'c //,fl "cc.0.r__. :':;,/p/f..:z'-. '!;3 YES 0 NO <br />14. ~F ENCE IN REPORT SY ATE I SPECTOR (Sign.,'%~ Agency. date' CONCUR ATTACHMENTf <br /> <br />~~ / 'Stci~ LOCAL RE:~'ES~~-7:tz~;~e~d,,~)~::,/~~ ~~~~~.:: i~~ACHMf'N~S-'~ <br /> <br />'-16. ~F eci.ER A I' ~W (Slg'1tur~, A9"f~'~~;' dat~j ,- , 1....,/ - I FEMA REVI EW flntria{s a(}d~e) <br />,It"" 'tAl. t:..-]A //../ ___~~_n._____~______ -'--- <br />FEMA Fornl 90-52, Jl\N 811~r'r'l1ed." HUD Form 4~_:11) <br /> <br /> <br />rro.nv" rrll ~ nrr-.,-.... <br />