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<br />.".. <br /> <br />OMS No. 3067-0033 <br />FEMA DECLARATION NUMBER <br /> <br />FEDERAL EMERGENCY MANAGEMENT AGENCY <br />NOTICE OF INTEREST <br />IN APPLYING FOR FEDERAL DISASTER ASSISTANCE <br /> <br /> <br />_-c~ <br /> <br />Oz.9'- eo. <br />The purpose of this form is to list the damages to property and facilities so that inspectors may be appropriately assigned for a <br />formal survey. <br /> <br />REQUIREMENTS FOR FEDERAL DAMAGE SURVEYS <br /> <br />A. DEBRIS CLEARANCE <br /> <br />F. PUBLIC UTILITY SYSTEMS <br /> <br />(1 <br /> <br />o On Public Roads & Streets including ROW <br /> <br />o Other Public Property <br /> <br />?' IB"Privale Property (When undertaken by <br />~, local Government forces) . <br />;""-:::"1'~-Jfr" - ;:1,1 :.ICd.I..':'/',1/'r,.... f'(:Jf'-c,.I-i' <br />D Structure Demolition .1 <br /> <br />o Water <br /> <br />o Storm Drainage <br /> <br />o Sanitary Sewerage <br />o Other' <br /> <br />OUght/Power <br /> <br />B. PROTECTIVE MEASURES <br /> <br />G. FACILITIES UNDER CONSTRUCTION <br /> <br />C(} <br /> <br />o Life and Safety <br /> <br />o Heal th <br /> <br />o Public Facilities' <br /> <br />I <br /> <br />r;::]Property 0 Stream/Drainage Channels <br />f!l,rr/r:: U'J:>/:,,:_ j-,J I' (',t1/~~..f :.,jY<J,j,~.1 <br />C. ROAD SYSTEMS <br /> <br />D Private Non.Profit Facilities.. <br /> <br />H. PRIV ATE NON-PROFIT F ACILmES.. <br /> <br />o Roads <br /> <br />o Streets <br /> <br />o Educational <br /> <br />o Medical <br /> <br />iFF <br /> <br />,4- <br /> <br />I:B1lridges <br />o Traffic Control <br /> <br />o Culverts <br /> <br />o Emergency <br /> <br />o Custodial Care <br /> <br />o Other. <br /> <br />o Utility <br /> <br />D. WATER CONTROL FACILITIES <br /> <br />I. OTHER (Not in above categories) <br /> <br />o Dikes <br /> <br />o Levees <br /> <br />o Dams <br /> <br />o Park Facilities <br /> <br />o Drainage Channels <br /> <br />o Irrigation Works <br /> <br />o Recreational Facilities <br /> <br />E. PUBLIC BUILDINGS AND EQUIPMENT <br />o Public Buildings <br /> <br />o Supplies or inventory <br />o Vehicles or other equipment <br />o Transportation Systems <br />o Higher Education Facilities <br /> <br /> <br />* Indicate type of facility_ <br />** Provide name of the facility and of priuate non-profit owner_ <br /> <br />NAME OF POLITICAL SUBDIVISION OR ELIGIBLE APPLICANT <br />/.</V1f ,1/ v,rc/.,v/ C;l/ <br />BUSINESS ADDRESS 7 <br />') If) ;? T - "Sr.) /) <br />NAME AND TITLE OF LOCAL CONTACT <br />3 .----c-~.s-:; flc:rr;r.,-{r- r - /1"'/LC__ <br />BUSINESS TELEPHONE NUMBER'11nclude Area Codp) <br />GiJ;;- g5.~--?~-;: <br /> <br />COUNTY ,} <br />2 F,,!ttr <br /> <br />ZIP CODE <br /> <br />q '-It) <br /> <br />HOME TELEPHONE NUMBER (lflclude Area Code) <br /> <br /> <br />~~ /' <br /> <br />FEMA Form 90-49, MA Y 82 <br /> <br />REPLACES EDITION OF MAR 80, WHICH IS OBSOLETE. <br />