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<br /> FEDERAL EMERGENCY MANAGEMENT AGENCY O.M.B. No. 3067'{) I 5 I <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 submining 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 />DECLARATION NO. PROJECT NO. FIPS NO. DATE CATEGORY <br />FEMA- 3;3/ -DR. f"L- jJ. t;cDrL Ce. LJ25~~9 550 ID- :J. 1- ff 3 <br />DAMAGED FACIL~ Jc WORK COMPLETE AS OF: <br /> Cr I 'I 01 9-)1-95 : r9 % <br />APPLICANT COUN~~~E <br />(J'lY C,f SU/J:) 'I I<;. flEe;, I?e:ADJ <br />LOCATION LATITUDE LONGITUDE <br />DAMAGE DESCRIPTION AND DIMENSIONS <br />-r; 1lLoi/i tJE '-:m~G\i6~ ~ (L 'it-! E S 4FETI LJr Li -- ,- /' <br />, I -z. t.. fL) C - Y b t2..... <br />l-I:u (Lru C AvJ t:. ~c. 0 fLL.c.. <br />SCOPE OF WORK de k~iJ (L E- s:, [L,2.1 pj~ <br />f:.WlcR C.~l)L V 2--- Ju /jgt C tl AJe (;E'6(2 h-c <br />12 0 f~c. II Lie:: Does the Scope of Work change the pre-disaster conditions at the site? D Yes ~No <br />Special Considerations issues included? D Yes ~NO Hazard Mitigation proposal included D Yes gNo <br />Is there insurance coverage on this facility?D Yes No <br /> PROJECT COST <br />ITEM CODE NARRATIVE QUANTITY IUNIT UNIT PRICE COST <br />J q 0 J..{)... er.pT f).~ J-l.o '~I,c.e (!) --.- J-.,S J- 0 f! /. t 0 <br />v 6li- f /VI'! C <br />-rc q~9q I'i, t,,1f o >Ie It m;AiFo I A \.s. }....g, .5Y/ ~, fs? 0 <br /> , <br /> [ <br /> '\ Xfl I'D <br /> 7u~ <br />':::::~~I:::I:\:::::I~::~~1j~::::':I~::::i:::I::::~,::1:::::::::1::::::::::::::::'::::::::::::::::::1:::::1:1:::::::::::::1:1::'1::::::'1:::11:::::::11:1:1:\:::::::::::I::::::III:I::!I:II::::\:!I:I::!:I:I:I::I:I!!:!:::::::::111:::::::1:::1:::1::1::::::::1:::1:::::::1:::!:::::!:::::::jl:\:iil\I\!:j!!:!;i:!:III:I:!:l!:=I::':i::ll:~:i!::i;:;::::,';::i::':::!:::'::::l:!::i!: TOTAL COST IJjf!9, ~D <br />PREPARED By:UiJl tflAAlA i >A <br />FEMA Form 90-9.1!. SEP 98 REPlACES ALL PREVIOUS EDITIONS. <br />