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<br />i /' OM8 No. 3067-0027 <br />..----b/---------. ...-. <br />FEDERAL EMERGENCY MANAGEMENT AGENCY 3. DECLARATION NO. <br />FEMA 2J I< . C 0 <br />4. INSPECTION DATE <br />- t, t.J <br />Q 5. WORK ACCOMPLISHED BY <br />1. TO" REGION_--e-- FEDERAL EMERGENCY MANAGEMENT AGENCY <br /> <br />2. APPLICANT (State Agency. CountY~-Citv. (trItT" ; PANO------ -----~- ~~~~::~~OUNT <br />. ------.1J.offI1L...c.o..~1>L I (J'y! ~ /) ;)U r'-' <br />7. WORK CATEGORY ("X" Applicable Bo;>() I DSR NO 6 PERCENTAGE OF WORK <br />[J EMERGENCY [J A ~ COMPLETED TO OATE <br />OJ [] PERMANENT 0 C [J DOE l'J FOG [] H 0 I 2 4 9 2 9 j ~2_ % <br />8. DAMAGED FACILITIES (Location, identification and descdptionJ 8A. FACILITY IN OR AFFECTS <br />C /J ~ II t:: /J /J Ii FLOOD PLAIN OR WET LANOS I <br />o "eX rfl.teHIIN l'I.e~e/l.vo,A ~,K <br />f { _D_YES ~NO '__1 <br />:<0' ....c1P~{.j~( R.oAO <br />[9:'DESCRI?TION OF DAMAGE ,oJ/} <br />I /I'JI'> '.s ,J:'".s ON I? OA 0""1'11' <br /> <br /> <br /> <br />L '00", ",,""'",," .""' J Ii {. I ~ <br />clf'/M b.,,,, .:. , e s ;u /l P S <>lI..e Auf's.s ~Avt' <br />fe"lpufl..Mt)' IIc(e~.s Five' s'/e.:, ::;)I'O)(:o~ j i"'d'5 <br />;(o:>~ 150 ') /S~50; 1'\"'0 so'. <br /> <br />DAMAGE SURVEY REPORT <br /> <br />DISASTER RESPONSE AND RECOVERY <br />(See instrucrions on reverse) <br /> <br /> <br />QUANTITY <br />fa) <br /> <br />UNIT <br />(b) <br /> <br />11. ESTIMATED COST OF PROPOSED WORK <br />._-----_.,-~---_.._. .>----. -~---,,------ ----- .-- <br />MATERIAL ANDIOR OESCRIPTION UNIT PRICE <br />~ ~ <br /> <br /> <br />COST (dollars) <br />le) <br /> <br /> <br />=-~ -I - -:- ~~-- <br /> <br /> <br />14. <br /> <br />..----,.. ..~ .---.. .-.--_____~__ ...1.._.........._...:.._. <br />---~-~---_. ..- <br />" "i~!~]W=,-~ - -. ., ^~"" -J..-_~:::- - -- <br /> <br /> <br />-..--- PECTOR(Si9n;t;;;:,~;nc~-:dare! ... ___m__ J 0 TO~Al:i8L: '~i~H'MENTS- <br />r#wA ~'ljI(f.'),/t./ i;JQ'ts~lND <br />NSPEcTOR (Signature, Agency, dat~---------- cONCUR-- A IT ACHMENTS <br /> <br />~-~~~ '.f~. ~:~~r.f-,JO A'i"fACHMENTS <br />. ~ J.Ll-9..(Z ~YES[] NO <br />FEMA ~EVitw1~/~ and date) <br />I <br />L_.___.._~_.. <br /> <br />13. <br />[3J <br />