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<br />.- <br />.. .. <br />--' <br /> <br />OMS No. 3067-0033 <br /> <br />Ii <br /> <br />FEDERAL EMERGENCY MANAGEMENT AGENCY <br />NOTICE OF INTEREST <br />IN APPLYING FOR FEDERAL DISASTER ASSISTANCE <br /> <br />FEMA DECLARATION NUMBER <br />LMA ",Iq- be. - <2..0 <br /> <br />DATE <br />() - .J. - ~cf <br />PROJECT APPLlCA TIQN NUMBER <br />'ex) ()c) <br />The puroose 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 />I <br />I <br />iCO <br /> <br />A. DEBRIS CLEARANCE <br /> <br />~ On Public Roads & Streets including ROW <br /> <br />Id! Other Public Property 'E> 0' 0 ~ e:> <br /> <br />o Private Property (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 />j;PA <br />=-- <br /> <br />~Sanitary Sewerage <br /> <br />o Light/Power <br /> <br />o Other. <br /> <br />B. PROTECTIVE MEASURES <br /> <br />G. FACILITIES UNDER CONSTRUCTION <br /> <br />~ Life and Safety <br /> <br />o Health <br /> <br />It- ~Public Facilities' Ae<..e5~ 'R.::A-o TO "'~ lft-O" <br />pili! '" ""''lEt> ""', <br />~ 0 Private Non.Profit Facililies" <br /> <br />-:!fl <br /> <br />~ Property <br /> <br />o Slr.am/Drainage Channels <br /> <br />---/ <br />- , <br /> <br />C. ROAD SYSTEMS <br />.Pq'Roads <br />i- % Bridges <br />o Traffic Con trol <br /> <br />H. PRIVATE NON-PROFIT FACILmES" <br /> <br />o Streels <br /> <br />o Educational <br /> <br />o Medical <br /> <br />J;1!l.Culverts <br /> <br />JKI Other'ENe"",,-,,,,,,,,,, <br />'FAILL..-\R..~ <br /> <br />o Emergency <br />o Utility <br /> <br />o Custodial Care <br /> <br />D. WATER CONTROL FACILmES <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 />. Indicate type of facility. <br />.. Provide name of the facility and of private non-profit owner. <br /> <br /> <br />NAME OF POLITICAL SUBDIVISION OR ELIGIBLE APPLICANT <br />G LA N ,., \ ~ G..",... 1"\ <br />BUSINESS ADDRESS ....) <br />o E. V,IZ.(,'N." fly..;- <br />NAME AND TITLE OF LOCAL CONTACT <br />/'YI , '- r-tvon:: L ...l .K 0 '-- L <br />BUSINESS TELEPHONE NUMBER (Include Area Code) <br /> <br />( ~ <br />0"'"\ lA y-.J'w , ~~ <br /> <br /> <br />~0 <br /> <br />c..c k ..., <br /> <br /> <br />M ~__A G C1<Z. <br />HOME TELEPHONE NUMBE R (Include Area Code) <br />, \ <;: <br /> <br /> <br />Od. G- '6 <br /> <br />FEMA Form 90-49. MAY 82 <br /> <br />REPLACES EDITION OF MAR 80, WHICH IS OBSOLETE. <br />