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<br /> <br />c <br /> <br />:co <br /> <br />F}! <br /> <br />C'~ <br /> <br />{'t:7 <br /> <br />OMS No. 306 ]-0033 <br />FEMA DECLARATION NUMBER <br />r=: --=r\ -t>R- c'o <br /> <br />21 !9~t..t <br />PROJECT APPLICATION NUMBER <br />077- 0'/660. <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 />FEDERAL EMERGENCY MANAGEMENT AGENCY <br /> <br />NOTICE OF INTEREST <br />IN APPLYING FOR FEDERAL DISASTER ASSISTANCE <br /> <br />DATE <br /> <br /> <br />REQUIREMENTS FOR FEDERAL DAMAGE SURVEYS <br /> <br />A. DEBRIS CLEARANCE F. PUBLIC UTILITY SYSTEMS !J*t W~ <br /> <br />o On Public Roads & Streets including ROW $ ta:,waler h-slorm Drainage cl reA a <br />n Qclo.0 <br />~ Other Public Property wtt'.."l ~ Colo. l<.1vex- c(Sanitary Sewerage 0 Light/Power <br />(I,,", """'\~ <br />o Private Property (When undertaken by 0 Other' <br />local Government forces) <br /> <br />o Structure Demolition <br /> <br />B. PROTECTIVE MEASURES <br /> <br />G. FACILITIES UNDER CONSTRUCTION <br /> <br />'I!'I Life and Safety 0 Health 0 Public Facilities' <br /> <br />l;8l Property IZl Stream/Drainage Channels. 0 Private Non.Profit Facilities" <br />dlOl"\,\ '\k. rue. Q.\~ ....,r,,,,- \\-.L I:.~ '"",,,,=- <br />C. ROAD SYS'tEMS H. PRIVATE NON-PROFIT FACILITIES.. <br /> <br />p <br /> <br />I8J. Roads <br />\'8t Bridges <br />1:& Traffic Control <br /> <br />1&t Streets <br />ll3t Culverts <br /> <br />o Custodial Care <br /> <br />o Educational <br /> <br />o Medical <br /> <br />o Emergency <br /> <br />o Other' <br /> <br />o Utility <br /> <br />D. WATER CONTROL FACILITIES L OTHER (Not in above categories) <br />t!!O Dikes 0 Levees l8l Dams . C C~ l8'Park Facilities R,~,J.Q.. \:>d< I:.. <br />~1O....d",....", <br />Q<;t Drainage Channels 0 Irrigation Works 01\ fuai.6 ~ 00 Recreational Facilities ""8-'<..0../ l-hk Ire;. \ <br /> <br />E. PUBLIC BUILDINGS AND EQUIPMENT <br /> <br />o Public Buildings <br /> <br />o Supplies or inventory <br /> <br />~ Vehicles or other equipment \ <br />Ioca+- ~ d ""'-~ <br />o Transportation Systems Cole . el~ <br /> <br />o Higher Education Facilities <br /> <br />. lndicate type of facility. <br />.. Prouide name of the facility and of private non.profit owner. <br /> <br />NAME OF POLITICAL SUBDIVISION OR eLIGIBLE APPLICANT <br />1 (lA~ OP ~QJW.l,) <br />8 USI NESS ADD ESS <br />250 N.cRT\1 <br /> <br />COUNTY <br /> <br />HE5A: <br /> <br />.::rc )I.) (' T (ct4 <br />St~ G.QNJ.D -:::.s-\}um~ I <br />f\1XY1. <br /> <br />2 <br /> <br />C.o <br /> <br />ZIP CODE <br />~Isn\ <br /> <br />NAME AND TITLE OF LOCA,L CONTACT <br />E~12, 6.01...\)1"'\ 1=\..t:x:>'tJi7LAI N <br /> <br />BUSINESS TELEPHONE NUMBER (Include Area Codr) <br />2tfL1. -!fR z <br /> <br /> <br />PHONE NUMBER (Include Area Cod,.) <br />2.q.5'"'~133; <br /> <br />FEMA Form 90-49, MA Y 82 <br /> <br />REPLACES EDITION OF MAR 80. WHICH IS OBSOLETE. <br />