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<br />_ _____ __.....L <br />FEDERAL EMERGENCY MANAGEMENT AGENCY <br />DAMAGE SURVEY REPORT <br />DISASTER RESPONSE AND RECOVERY <br />(See instructions on reverse) <br /> <br />0:\18 No. 3061-UOn <br />3. DECLARATION NO. <br />FEMA G , . , C () <br /> <br /> <br />1. TO" <br /> <br />REGION ---8-- FEDERAL EMERGENCY MANAGEMENT AGENCY <br /> <br />5. WORK ACCOMPLISHED BY <br /> <br />o CONTRACT <br />(XFORCE ACCOUNT <br /> <br />2. APPLICANT (Stare Agency, County, City, &re.J - : PA NO. ------------ <br />__~......JL.u A t~~.-.--,-~J)$L-~ <br />7. WORK CATEGORY (UX" Applicable BoxJ DSR NO. <br />D EMERGENCY 0 A 9'B : <br />Q] 0 PERMANENT 0 COD D E 0 FOG 0 H 0 I I <br /> <br />2~907 <br /> <br />I <br />-tB. PERCENTAGE OF WORK <br />I r- COMPLETED TO DATE <br />[3] <br /> <br />% <br />BA. FACILITY IN OR AFFECTS <br />FLOOD PLAIN OR WET LANDS <br /> <br />8. DAMAGED FACILITIES (Location, identification and tjescriptionJ <br />~o /2. J 5 I tM.... /<,.0 r$11l,J(0 c...~J7 /.,..e 10 755,.,: <br />fVOAfI,- ~'. 6'/",....,",o,.s svfJ,(lIaf !<-OAO-:(J 'w,Je I <br />9. DESCRIPTION OF DA~ j j J f: ! j <br />r I V I /()!JVf"" 1<0A tA//lv /o"f ,. 'vC I.., IA,.,cf 0, .. e.s <br />..c:;"" 0/1",,, 1'1"'... ) I <br />10(4/;0,",S /'Sl,.j 0"" /llIht,...p",f. <br /> <br />DYES <br /> <br />9(.NO <br /> <br />/II <br /> <br />-+::s..<. <br />~..s <br /> <br />I <br />~ <br /> <br />10. SCOPE OF PROPOSED WORK <br />Co",!.I,,~<f lertt20/lllflf <br /> <br />1/ (!(J (' S. 5 <br /> <br />Id <br /> <br />1111 /l(/"J S,/r> ~ <br /> <br />QUANTITY <br />la) <br /> <br />UNIT <br />Ibl <br /> <br />11. ESTIMATED COST OF PROPOSElo WORK <br />... ..------., ----_.- - - ---. ---.--.---.-.--- <br />MATERIAL AND/OR DESCRIPTION <br />Ie) <br /> <br />UNIT PRICE <br />(dl <br /> <br />COST fdofJarsJ <br />tel <br /> <br /> <br /> <br />,. <br /> <br /> <br />--+---. <br />_mF-_____~~=-~L=-=l~~-- -- <br />:::1__-------- n:::=t ]----- <br /> <br />12, EXISTING INSURANCE (Typel : ;MOUNT j QJ TOTAL'" S <br /> <br />13. RECOMMENDATION Y FED , SPECTOR (Sif;~;a'tur('_AqL'flCv,-datJ- - -- -----I---EiIGIBLE-@j- <br />~ ' . 1.1.~___ F U.....L-fJ..ft-._--.k- 7.k,1' ~YESLJ NO <br />ATE lNSPECTO~ture. Agency. date} I CONCUR ATTACHMENTS <br /> <br />~~teJ~.8~;j ~~~~:: ATTACHMENTS <br />- I FEMA RfvrElflnltialS and date) <br />/' I <br />/, I <br /> <br />