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<br />---~-~.,:./~--,-- <br />FEDERAL EMERGENCY MANAGEMENT AGENCY <br /> <br />DAMAGE SURVEY REPORT <br /> <br /> <br />OMI3 No. 3067-0027 <br /> <br />'i <br /> <br /> <br />1. TO" REGION_ 8 FEDERAL EMERGENCY MA~AGEMENTAGENCY. __ n____ .__ . 5. ~::~;::;;L1SHEO BY <br /> <br /> <br />2. APPLICANT (State Agencv.. County, City, etc~1 PA NO. I)<FORCE ACCOUNT <br /> <br /> <br />7. WORK CAT!:!o~y~WPlicab/~:'(~ I D's/l~L--01Jz;z;i)m 6. PERCENTAGE OF WORK <br />o EMERGENCY DAD B : COMPLETED TO DATE <br />[2] D.PERMANENT JXc [J DOE 0 F LJ G DH SJI 211 932 [Br) #I S <br />8. DAI"'lAGE~ F1.ILlT1 ES (LoCdtion, Idr:t~'ficatiQn andj,SCriPtion1 Co !l. J 70 SA. FACILITY IN OR AFFECTS <br />, . J "1-'1' C f1 3 V "~D FLOOD PLAIN OR WET LANDS <br />11\1'/ ('/llVeS.!,".v(, 0'" 0 n~ <br />J I 0 YES serNO <br />9. DESCRIPT'ONOFD~?c; IA,J, 'e '2.:!]fJve /Z.()Il~ 1 I. f!__l I 1/ r <br />KO/JOwAy /65f ";'0 IIlI'I .s "res /J f s;)\' s. es .k_qTfJ:..rr <br /> <br />/:15 I /00' /'25' I ,20<J / 2. 00 / jl",.o 370 ~ GRllvel /"5+ .2I'~O/ <br />) ) ) I I <br />Af It:,,. .s,l~..s. Cv/~(,fl t loST (/3" J{ 60') Cn{J 0,., (v d 3,g <br /> <br />10. SCOPE OF FRO POSED WORK I I j <br />IJ ,<<t.O/i'<hl"i<t:I BVIl/vA;O/V /5 ;e(>Co;iMe"'O~ <br /> <br />lelt'/l.,..;oJr +(',q~.b.H1 of /{efl/J.'R, .,.., .st'vt'lle /~J.slJe eo....JIlY. /<t'p4re <br /> <br />eMbll",j(",j "I 1l6.d lo</'O./.''',.JS . (<{'plnce c "Ive~t) 1<~l'Ivel. <br /> <br />No sn/vlJ::!;, <br /> <br />DISASTER RESPONSE AND RECOVERY <br />(See instr'uctions on reverse) <br /> <br /> <br />o <br /> <br /> <br />11. ESTIMATED COST OF PRQPOSEDWOAK <br />-----~. .....------------ <br />MATERIAL ANDIOR DESCRIPTION UNIT PAICE <br />~ ~ <br /> <br /> <br />~;~M,..f <br /> <br /> <br /> <br />OUANTITY--U'Ni:;---T-'- . <br />(aJ lb) <br /> <br /> <br />I <br />"_~~un, --y;-;---t _rT(-lTn - --t-- - , r- <br />_n_ --- _ -I U\ .L~L_ _ ~~~--- ------t--- _______. <br />_ _--= ..~...=~ -~u-l- <br />+-. ---_+__-~_.._nn <br />12. EXISTING INSURANCE!TYP;)"-H_-~}:~OU:T . Jm TOTA,L~u S.. <br />13. AL II'JSPECTOR rSi!lnatufI', Agencv, date} I ELlGIB~_~ I]] ATTACHMENTS <br />~ *ATE CttiliR (si;i,;;iu'e~;l!!. d~t~..i-. ------ ------..1 ~~:~;J NO ATTACHMENTS <br />-4'-/0 -w. r~EsDN9_ n__~_._, <br />ncy, date) CONCUR ATTACHMENTS <br />K.::-LO.:: X-<.t.... I)E.YES ==:J NO <br />TFEti:.\ REVI EW N;,{;;:;;s and date) <br />I <br /> <br />8" <br />3/y I, r/lv~!oj,jA"~/ <br /> <br />il< <br /> <br />