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<br />LJ2G46 <br /> <br />~' <br /> <br />STATE OF COLORADO <br />DAMAGE SURVEY REPORT <br />DISASTER RESPONSE AND RECOVERY <br /> <br />1. TO COLORADO DIVISION OF DISASTER EMERGENCY SERVICES <br /> <br /> <br />2d~L ANT (State Agency, <br /> <br />7.~ CATEGORY("X"~ableBoxl <br />MERGENCY D A <br />PERMANENT D C D D D E D F D G D H D I <br />8. DAMAGED FACILITIES (Location, identification and description) <br />E'mE-€~C;U~'I PRO'T"C(! rIVe- P7E.ASC/Re"S. <br /> <br />I PA NO. <br />I <br /> <br />:DSCOO_~ <br /> <br />9, DESCRIPTION OF DAMAGE <br />C"'-cP~L. IlIV~,eetJ<<>O ADblrlt:JA! <br /> <br />10_ sCOPECPR5=wO;TT/1~;/et> Sh'EE7.s) <br /> <br />QUANTITY <br />lal <br /> <br />11. ESTIMATED COST OF PROPOSED WORK <br />MATERIAL AND/OR DESCRIPTION <br />lei <br /> <br />UNIT <br />Ibl <br /> <br /> <br />rNReF <br />P,anet>L.. <br /> <br />12. <br /> <br /> <br />13. <br /> <br />I <br />I <br />PECTOR (Signature, Agenc ~ date) ,--- <br />- 3 (-g~ <br />T B Y STATE I NSPECTOR (Signature, Agency. date) <br /> <br />14_ <br /> <br />15. CONCURRENCE IN REPORT BY LOCAL REPRESENTATIVE (Signature, Agency. date) <br /> <br />16, <br /> <br />"::I Evt EW (Signature, Agency. date) <br /> <br />~EVI EW (Initials and date) <br /> <br />3, DECLARATION NO, <br /> <br /> <br />~NTRACT <br />RCE ACCOUNT <br /> <br />6, PERCENTAGE OF WORK <br />COMPLETED TO DATE <br />100% <br /> <br />8A. FACILITY IN OR AFFECTS <br />,"-LOOD PLAIN OR WET LANDS <br /> <br />~ES D NO <br /> <br />UNIT PRICE <br />Idl <br /> <br /> <br /> <br /> <br />TOTAL" $ 3 <br /> <br />ELIGIBLE <br />D YESD NO <br />CONCUR ATTACHMENTS <br />DYES D NO <br />CONCUR ATTACHMENTS <br />DYES D NO <br />