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<br />FEDERAL EMERGENCY MANAGEMENT AGENCY 0.M.8. No. 3067-0151 <br />PROJECT WORKSHEET Expires April 30, 2001 <br />PAPERWORK BURDEN DISCLOSURE NOTICE <br />Public reporting burden for this form is estimated to average 30 minutes. The burden estimate includes the time for reviewing <br />instructions, searching existing data sources, gathering and maintaining the needed data, and completing and submitting the forms. <br />You are not required to respond to this collection of information unless a valid OMB control number is displayed in the upper right <br />comer of the forms. Send comments regarding the accuracy of the burden estimate and any suggestions for reducing the burden to: <br />Information Collections Management, Federal Emergency Management Agency, 500 C Street, SW, Washington, DC 20472, <br />Paperwork Reduction Project (3067- 0151). NOTE: Do not send your completed form to this address. <br /> <br />DECLARATION NO. PROJECT NO. FIPS NO. DATE CATEGORY <br />FEMA- 3i 3i ... H. C€ol2. c"E {)L5'~1D95'~D / D-z..9- 9 P 35 <br />-DR- f.b <br />DAMAGED FACILITY c.. ~ WORK COMPLETE AS OF: <br /> I J Y WI De Q.-j'7~92 . j (J(j % <br /> <br />APPLICANT I COUNl)\" t.\ r:::' <br />c/rv t!)e=' SuJJuv Id €'c ~.4C1 LJttUc <br /> <br />LOCATION <br /> <br />LATITUDE <br /> <br />LONGITUDE <br /> <br />DAMAGE DESCRIPTION AND DIMENSIONS <br />-4 -?!2.c,\J,j LE ?t2cTE:C-r;D~ f'()(l.. ---rUE ~~riiT1 Dr C/7i2EJ{)~ - ~t2.L <br />./-I LJ.f2- fLU~_t>n0 c r;; EO ~ ;:: E <br /> <br />SCOPE OF WORK <br />.l!YYl&~r;cuCY ';J'cl rC6~e ()'/64-~LJILEs;, ~UlIV~ J-lue.rL{ca-u~ bcoR.Ce <br /> <br />Does the Scope of Work change the pre-disaster conditions at the site? <br />Special Considerations issues included? 0 Yes r8.. No <br />Is there insurance coverage on this facility?D Yes fia'No <br />PROJECT COST <br /> <br />DYes fSlNo <br />Hazard Mitigation proposal included 0 Yes IS!l' No <br /> <br />/ 9o~ .C:;cpj- ,),;J-J.,J.J '-=?tJl/c.c OuG:TI'lVle <br />2.. qo 30 ,<)epT 2'2. RervYfA-\ VcJ,C Ie <br />~ <br />/4 <br />/ /ff/f) ) <br />/ rj, IV/, <br />/ I /' <br />l / <br />\ /' <br /> <br />- <br /> <br />I /_. /]/ <br />i;.) J().;:5S <br />1 ( S. 01.) <br /> <br />1-5 <br />LS. <br /> <br />COST <br />UJ'-I/>.4 1 <br />/ / SffO <br /> <br />ITEM CODE <br /> <br />NARRATIVE <br /> <br />QUANTITY/UNIT <br /> <br />UNIT PRICE <br /> <br />:.:,::::::::I:::::I:::'!:::I:::::I:::I:::::;::::1:1:::::::::!:::::::~::::::.i:::::!:I:!:::I:::::::::I::::::::1:!:::il:I::::l:!::I:::::::1;;::::;:I:::::1:::l[::j::::[:I;:I:::::::i:::::i:::l:::::1:::::::i:l,::::i:::::::l:i::::ll:i:!:i:l!!:;::\l:!::l:lj::::l::::::~::l:!::::!I:~:I\!::\I[:!!I:I\::!\::l\i:::!~~!!!:I::.lll:i:::\:!)::i:l~\:I:l\:[i[!II:::!::[i:::i:i\ TOTAL COST <br />PREPARED BY: fhv.'flnf-(JJL >f-. <br />FEMA Form 90-!i'{ SEP 98 REPLACES ALL PREVIOUS EDITIONS. <br /> <br />:2J~5'H1 <br />