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<br />FEDERAL EMERGENCY MANAGEMENT AGENCY <br />NOTICE OF INTEREST <br />IN APPL YING FOR FEDERAL DISASTER ASSISTANCE <br /> <br /> <br />..c ~ <br /> <br />.. <br /> <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 />co <br /> <br />A. DEBRIS CLEARANCE <br /> <br />~. On Public Roads & Streets including ROW <br /> <br />o Other Public Property <br /> <br />o Private Property (When undertaken by <br />local Government forces) <br /> <br />F. PUBLIC UTILITY SYSTEMS <br /> <br />J"5iWater <br /> <br />8 Storm Drainage <br /> <br />cP,,4 ~ Sanitary Sewerage <br />=-- <br /> <br />OUght/Power <br /> <br />o Other. <br /> <br />o Structure Demolition <br /> <br />B. PROTECTIVE MEASURES <br />J8J' Life and Safety <br /> <br />G. FACILmES UNDER CONSTRUCTION <br /> <br />c.o <br /> <br />r:zl Heal th <br /> <br />o Public Facilities' <br /> <br />~ Property <br /> <br />i:2q Stream/Drainage Channels <br /> <br />o Private Non-Profit Facilities.. <br /> <br />C. ROAD SYSTEMS <br /> <br />H. PRIV ATE NON-PROFIT FACILITIES.. <br /> <br />o Roads <br />~;I ~ ,2!J Bridges <br />o Traffic Control <br /> <br />o Streets <br /> <br />o Educational <br /> <br />o Medical <br /> <br />o Culverts <br /> <br />o Emergency <br />o Utility <br /> <br />o Custodial Care <br /> <br />o Other' <br /> <br />D. WATER CONTROL F ACILmES <br /> <br />('0 <br /> <br />00 Dikes <br /> <br />.IE Levees <br /> <br />o Dams <br /> <br />I. OTHER (Not in above categories) <br />Idl Park Facilities <br /> <br />o Drainage Channels <br /> <br />o Irrigation Works <br /> <br />etJE <br />- <br /> <br />IX 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 Syslems <br />o Higher Education Facilities <br /> <br /> <br />* Indicate type of facility. <br />.. Provide name of the facility and of private non-profit owner. <br /> <br />NAME OF POLITICAL SUBDIVISION OR ELlGIB <br />lOW 1\/ or. <br />BUSINESS ADDRESS <br />bRA-- vE <br />NAME AND TITLE OF LOCAL CONTACT <br />olilt-L D W(J()D <br />LEPHONE NUMBER (/ncludli' Area Code) <br />/! <br /> <br /> <br />t!.() <br /> <br /> <br />7'A <br /> <br />ZIP CODE <br />'l.? <br /> <br />-1M <br /> <br />IiQf{ <br />H~TELEPHONE" NUMBER (Jnclud~ Area Code) <br />() '" - 5'J. 7-- <br /> <br /> <br />FEMA Form 90-49. MA Y 82 <br /> <br />REPLACES EDITION OF MAR 80, WHICH IS OBSOLETE. <br />