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<br />COUNTY <br /> <br /> <br />FEDEAA~RGENCY MANAGEMENT AGENCY , e. <br />PRELIMINAWDAMAGE ASSESSMENT SUMMARY <br /> <br />PART 1- APPLICANT INFORMATION <br />NAME OF LOCAL CONTACT <br /> <br />DATE <br /> <br />aalance $ <br /> <br /> <br />PHONE NO. <br />Pu. ~~, I <br />DATE FY BEGINS <br /> <br />POPULATION <br /> <br />Balance $ <br /> <br />CA TE- NO. OF <br />GORY SITES <br /> <br />PART II - COST ESTIMATE-SUMMARY (COMPLETE SITE ESTIMATE BEFORE SUMMARIZING BELOW) <br />POTENTIAL LOCAL FUNOS FOR RECOVERY <br /> <br />TYPES OF DAMAGE <br /> <br />COST ESTIMATE <br /> <br />FUND/ACCOUNT <br /> <br />_' AVAILABLE BALANCE <br /> <br />f3 <br /> <br />r/OD L F;, /j Va", .'00...J <br />S i.f-.. $ <br />Ge.... AfIo.c.l......"",---\- <br /> <br />97.0<90 <br />/ <br /> <br /> <br />t7t:>iJ <br />PART III - DISASTER IMPACTS (USE SEPARATE SHEETS IF NECESSARY) <br /> <br /> <br />TOTAL <br /> <br />A. GENERAL IMPACT <br />1. Identify and describe damages which constitute a health and/or safety hazard to the general public. <br /> <br />2. Population acNersetv affected directty or indirectly by the loss of public facilities or damages. <br /> <br />3. What economic activities are adversely affected by the loss of pUblic facilities or damages? <br /> <br />B. RESPONSE CAPABI LITY: Can the applicant respond and recover from the damages quickly and without degradation of public services? Describe. <br /> <br />>1" <br />/ <br /> <br />C. IMPACT ON PUBLIC SERVICES IF DECLARATION IS NOT MADE: e.g" Deferral of permanent repairs, impact on ongoing services and capital <br />improvements, etc. Describe. <br /> <br />NAME OF INSPECTOR <br /> <br />AGENCY <br /> <br />PHONE NO. <br /> <br />FEMA Form ~O. JAN 84 <br />