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<br />
<br />ENCY MANAGEMENT AGENCY
<br />AGE ASSESSMENT SITE ESTIMATE
<br />PART I - APPLICANT INFORMATION
<br />NAME OF LOCAL FPNTACT
<br />I6L4 l.A~ e1.A-1 Ii 1/)(1"
<br />PART II - SITE INFORMATION
<br />KEY FOR DAMAGE CATEGORY (U.. appropriate lelte,..1n the "ut.6ory" blocJu"eJow)
<br />
<br />
<br />
<br />SHEET OF SHEETS
<br />DATE
<br />. '27- (f
<br />
<br />PHONE NO.
<br />S7J-St?:J3
<br />
<br />a. DEBRIS REMOVAL
<br />b. PROTECTIVE MEASURES
<br />c. ROADS AND BRIDGES
<br />
<br />d. WATER CONTROL FACILITIES
<br />e. PUBLIC BUIL.DINGS
<br />f. PUBLIC UTILITIES
<br />
<br />g. FACILITIES UNDER CONSTRUCTION
<br />h. PRIVATE NON-PROFIT
<br />I. PUBLIC RECREATION
<br />
<br />SITE CATE- LOCATION (Use mGP loeatlon. addn... etc.) 7/P..o/>p"r t!1i! ..,~-'<
<br />NO. GOillly
<br />
<br />LA.k~ !"oAb
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<br />
<br />.:< C-
<br />DESCRIPTION OF DAMAGe
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<br />
<br />IMPACT:
<br />
<br />" COMPLETE
<br />
<br />COST ESTIMATE
<br />
<br />(/ 3(7~o,
<br />
<br />SITE
<br />NO.
<br />
<br />CATE-
<br />GOX
<br />C-
<br />
<br />LOCATION (U.. map location, c:ac:kITea. etc.) 7RA' P ..p ~
<br />"J.f?-S.S
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<br />DESCRIPTION OF DAMAGE ........l>' (I..,. - ,
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<br />IMPACT:
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<br />~~J
<br />
<br />(!
<br />'1'1
<br />
<br />" COMPLETE
<br />, I>
<br />()
<br />
<br />COST ESTIMATE
<br />:z. a "C'
<br />
<br />SITE CATE.
<br />NO. GOflY
<br />
<br />LOCATION (UN rnG,P locGtIon. add...... etc.} i:!-C/et ",'(
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<br />DESCRIPTIONOFDAMAGE .....At-i'-e ch"...--Jp/ Ch41?9'''''' aC<'-R 7<7 eV/C/PIPf-s IAJAh;/,'ty
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<br />IMPACT'Q?'tf'jJS PI" -Pn'l'I1'''''-<>/f' 5/'",e,-/<1' LeoK "COMPLETE
<br />04+ 7 h /5 ,
<br />
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<br />COST ESTIMATE
<br />
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<br />SITE cATE. LOCATION (U.. mop location, oddreg. etc.) C 4J q Yi -{ '1
<br />NO. GbRY 0/C-e ~J( #
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<br />OESCRIPTlONOFDAMAGE S,NS 5/>",75 "p_
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<br />
<br />IMPACT: " COMPLETE COST ESTIMATE
<br />d s: 7p, () /tJ.I CJC7CJ
<br /> L//5
<br />NAME OF INSPECTOR AGENCY PHONE NO.
<br />lip ..v 51'(1RLJL ~ H _-A OFFICE I HOME
<br /> J..J" - "''''' H' ~f'J'-PO",
<br />, /1", '. , >- ~ , "
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