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<br />(,tJ2G33 <br /> <br />STATE OF COLORADO <br />DAMAGE SURVEY REPORT <br />DISASTER RESPONSE AND RECOVERY <br /> <br />3, DECLARATION NO, <br /> <br /> <br />5, WORK ACCOMPLISHED BY <br /> <br />o CONTRACT <br />~DRCE ACCOUNT <br /> <br />6. PERCENTAGE OF WORK <br />COMPLETED TO DATE <br /> <br />% <br />eA. FACILITY IN OR AFFECTS <br />FLOOD PLAIN DR WET LANDS <br /> <br />~ ONO <br /> <br />1. TO COLORADO DIVISION OF DISASTER EMERGENCY SERVICES <br /> <br />2 APPLICANT (State Agency. County.. City, ere.) <br />ToWN Del. ~ <br /> <br />7. WORK CATEGORY '''X'' Appt;cable Box) <br />o EMERGENCY 0 A 0 B <br />ERMANENT ""'-0 DOE 0 FOG 0 H 0 I <br />8. DAMAGED FACILITIES (Location. identification and description) <br />(! In; P/7.e,t:S. /N TOCtl/J L/.uirs <br /> <br /> <br />I PANO, <br />I <br /> <br />:DSRNCO_ II <br /> <br />9, DESCRIPTION OF DAMAGE . <br />jJG.eKS aJere. .f'IooLJcLJ by wo ~,eeAes. /~. -!he Rtwr 7SAAJ~ <br />and o/Je fJRet:l~ OM /JA/~S &e~.e. tJebl€!./S a/}(7 S't/-/-Ft//i1ed <br />S/)/'/A/kler S; s -",.::. SewerL.//v~s ~/u.fled A-PLJ ;2oA-PS <br />td ;4-5// EZ> . I <br />10, S<;QPE OF fROPOSED WORK <br />I, 'cr1cue. Sf,r//lk:krS'y-sffm t2/'N1 t!/et2/Z- /.,(I-~d ~ Rt::'S~oaMS. <br />:(. 9""0/.,t. ",L' s~er hhe. FDe' e/f't?/J~rP' 4A't //oo..fLYod~~/Qt!'ed <br />. RrQ.'..e s~eek>. (2.4 Zo.f!l.)( So tvlPe x z. /)~J") ~/2U:5Jed Jr<1vel. <br /> <br /> <br />OUANTlTY <br />lal <br /> <br />UNIT <br />lb) <br /> <br />UNIT PRICE <br />(d) <br /> <br />COST (dollars) <br />lei <br /> <br />_432- <br />?I 4- <br /> <br />-?Jd~ <br /> <br />~ <br /> <br />#'tf'e'. ~d <br /> <br /> <br /> <br /> <br />16. <br /> <br />'lEVI EW (Signature, Agency. date) <br /> <br />CONCUR ATTACHMENTS <br />DYES 0 NO <br />CONCUR ATTACHMENTS <br />OYESO NO <br />qeVI EW (Initials and date) <br /> <br /> <br />15. CONCURRENCE IN REPORT BY LOCAL REPRESENTATIVE (Signature, Agency, date) <br />