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<br />, " <br />'<, <br /> <br />,< <br /> <br />OMB No. 3067.0033 <br /> <br />FEMA DECLARATION NUMBER <br />rl?f1'1f - 719 - tJlZ - cO <br />OAT$) <br />/Tf;C-vS-r Ol.( I'? frY <br />PROJECT APPLICATION NUMBER <br />S- - e::> OOD 0 <br />The purDOSe 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 />FEDERAL EMERGENCY MANAGEMENT AGENCY <br />NOTICE OF INTEREST <br />IN APPLYING FOR FEDERAL DISASTER ASSISTANCE <br /> <br />REQUIREMENTS FOR FEDERAL DAMAGE SURVEYS <br /> <br />/""/~ <br /> <br />A. DEBRIS CLEARANCE <br /> <br />~ Public Roads & Streets including ROW <br /> <br />~ 0 Other Public Property <br /> <br />o Private Properly (When undertaken by <br />local Government forces) <br /> <br />o Structure Demolition <br /> <br />F. PUBLIC UTILITY SYSTEMS <br /> <br />o Water <br /> <br />o Storm Drainage <br /> <br />o Sanitary Sewerage <br />o Other' <br /> <br />OUght/Power <br /> <br />R PROTECTIVE MEASURES <br /> <br />G. FACILmES UNDER CONSTRUCTION <br /> <br />o Life and Safety <br /> <br />o Health <br /> <br />o Public Facilities. <br /> <br />o Property <br /> <br />o Stream/Drainage Channels <br /> <br />o Private Non-Profit Facilities" <br /> <br /> C. ROAD SYSTEMS <br /> fD1(.,ads o Stree ts <br />F/f fr ~dges ~verts <br /> o Traffic Control o Other. <br /> <br />H. PRIVATE NON-PROFIT FACILITIES.. <br /> <br />o Educational <br /> <br />o Medical <br /> <br />o Emergency <br /> <br />o Custodial Care <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 0 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 />. Indicate type of facility. <br />** Provide name of the facility and of private non-profit owner. <br /> <br />NAME OF POLITICAL SUBDIVISION OR ELIGIBLE APPLICANT <br />G.-4tl..t"'"( 6<:.../J LOU IV n <br />BUSINESS ADDReSS <br />10() <br /> <br />COUNTY <br />2 ("'-"'K-PlEI..-V <br /> <br /> <br />NAME AND TITLE OF LOCAL CONTACT <br />~07V~ t>OWUS'-t' <br /> <br />&/h? <br /> <br />~ tv ClOV > f' "_fP....e~ I <br />f-l5it1j.'C.'~ ..f("1'~x.,,,..J, cv_ <br /> <br />to <br /> <br />ZIP CODe <br />v/tGo/ <br /> <br />c.f('oot.. <br /> <br />~r <br /> <br />BUSINESS TELEPHONE NUMBER (Include Arecz C e) <br />4 ~~J-::' ~/II { k~ <br /> <br /> <br />HOME TELEPHONE NUMBEA (/"clude Area Code) <br />- t;;;;? fC, C:rO s <br /> <br />FEMA Form 9G-49. MA Y 82 <br /> <br />REPLACES EDITION OF MAR 80, WHICH IS OBSOLETE. <br />