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<br /> _'It. -; RE1"i~/.H'~A;-~ Y T>.-:". ,GE ~,SSl:SS:-:tN r Sl rE -5 j':"4"fE ..._ ____ L4>12~/N~__
<br /> _ _.____ ._ _ . __n ---_._- ----. -..,------.- u "'-'---
<br /> PART 1- APPLlC,"..NT t~~t'-:;':-i'.',~T1ON
<br />. Z{i~Y, I '--'--TC>:;F ;;;CO~JCCREEr ]~~:L:~~_;_~::~~~ ~~~~~~r:f '--
<br /> PART II - SITE INFORMATION
<br />K'E'y"""'t'oAD-A;:"'AGE CATEGORY (U.e appropriate letters in the "category" bloclu below) -- ~----- --.-. .--. .~--- ----
<br /> .
<br />a. DEBRIS AEMOV AL d. WATER CONTROL FACILITIES g. FACILITIES UNDER CONSTRUCTION
<br />b. PROTECTIVE ME ASU RES e. PUBLIC BUILDINGS h. PRIVATE NON-PROFIT
<br />c. ROADS AND BRIDGES f, PUBLIC UTILITIES I. PUBLIC RECREATION
<br />SITE CATE. LOCATION (Use map loeolion. oddre... etc.)
<br />NO. GORY
<br />I C. LntJ ~ oW IlVE O"tiK Cl2e"cK CJa:>~hJA.
<br />D;:;t.IPTlON OF DAMAGE -
<br />'A.s~D Odr &/ST//tJ{. "l'zx, .0 Cut.J/clZr. - hEA?~.e;11 (V k?c: P<../I(YV f! 0,p/J"DEZ>.
<br />~/Z~ R~.-?7I9'''''J,..J6 ; #Ew' Ct/it/EZr /'JAJD E",.2J A,o.l"'Ro/'le /I e,"'.J$7A!Ue:T70-d .-t/ / &./AI()~
<br />/fl?~R().:J€h}EI(//.
<br />IMPACT: .t:IzeSGNTZ Y " COMPLETE COST ESTIMATE
<br />RoIQ'V 7EH>P' c.t.oS<Ef:;; -m ~rF;lc- - t9.A6W .
<br /> ..50 2~ oOo..~O .. .
<br /> .
<br />SITE CATE. LOCATION (Use map location, addre.... etc.)
<br />NO. GORY
<br />2 C mt'/";r~.~>~-'?.c ~/~ Ctzoss/AJ6 .'. . . ....:.'.'l
<br /> ,. '," '" .
<br /> . . "
<br />. :.DESCRIPTlON OF DA~AGE~) '.:' -'~;Y-}r~,v:".-'- ": : . .... ;. " .', . ".. ..,...,..:..;....
<br />z;,../TIl9h eD - j:?:; ,.9;' ~. ' t
<br />~,Y~)'fsCwBf)-:f- '6/1il(ii&'~r PJ/~I.~ /lr ~h6#~
<br />;;?o~t)W,q1l ot/E-e 7Z>P,PrFO /9,uD ~"'s#eZJ t:1(,/r - LDS~ ",,,c- R.....o ,16RRV~~" ,AwD Asp/I
<br /> -
<br />IMPACT: ~Jt!FfiC!t: '" COMPLETE COST ESTIMATE
<br />RMt::> 74'A?~ ~t::> - .;04...> .:l'pE..,) ON t:1Z.HVtC. 5o~ /t ()OO.oo ..... .'
<br /> .-...... '.' . \
<br />SITE CATE- LOCATION (UN map location. addreu. etc.1
<br />NO. GORY
<br />3 C. SI-IRR.P /Ne OI9~ (!~clC ClIZ"ssntJG.
<br />DESCRIPTION OF_DAMAGE fI v0r7C,re ., .
<br />7' l::h/J Cv{.t/E/lr/~'4, ~t) . IA/ I Dc- S T-eee,,- PtJA<S~D ov-r - 6/I..JC 6,c>o~EC>
<br />c.05S tJ.r S 77e.l/ c-rv /2C" Ro/'/ow,r9 V f S"VZr/1~Ali-,.
<br />IMPACT: 7/Z/JF,c)c... K€ :ROt,!;r;r- z> % COMPLETE COST ESTIMATE
<br /> RorrD Ct.l)$6D)
<br /> 0 $0,060.00
<br />SITE CATE. L.OCA TION (U.e mGp localion. oddr-e... etc.)
<br />NO. GORY
<br />L/. C. BtEU- .t7vc t),c K Ce€{!!;"K Crea=/Nt;
<br />DESCRIPTION OF DAMAGE
<br /> . 40 (:-O.vc, I ROADW4 V W/9S#eD O,/r: {})(/U~ '/Ep>PoRA-ey $R /.066"
<br />'l Crnp
<br />('R6:ZIN C, /j.) ,c;UI (!E .
<br />IMPACT: % COMPLETE COST ESTIMATE
<br />RoJ9V --n;/nP CwUD - t.::?~N vU) /G/n/f> 8.eI06C 0 ~0ooo. 0 C>
<br /> .
<br />NAME OF INSPECTOR lAGENCY 4v PHONE NO.
<br />V/JLc ;:/Yet; {'''C.D VII/ O,'g~~/_ SOl" I ~.r~-.....Q 74
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