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<br />FEDERAL EMERGENCY MANAGEMENT AGENCY O.M.B. No. 3067-0151 <br />PROJECT WORKSHEET Expires April 30, 2001 <br /> <br />PAPERWORK BURDEN DISCLOSURE NOTICE <br />Public reporting burden for this fonn 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 fonns. <br />You are not required to respond to this collection ofinfonnation unless a valid OMB control number is displayed in the upper right <br />comer of the fonns. Send comments regarding the accuracy of the burden estimate and any suggestions for reducing the burden to: <br />Infonnation 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 fonn to this address. <br /> <br />DECLARATION NO. PROJECT NO. FIPS NO. DATE CATEGORY <br />FEMA- E I ,g J -DR- r L H-c.e:ol2..C€ 0;;'5" (p 95"5"0 /0 - ;l9- 9 f b <br />DAMAGED FACILITY WORK COMPLETE AS OF: <br />GiN LtJ t be 9';'1-9; : 99 % <br />APPLICANT c; T' Y to P COUNTY <br />So.vv' -.-ISJes PCAC-.;/ OAfJc <br />LOCATION LATITUDE LONGITUDE <br /> <br />DAMAGYESCRIPTION AND DIMENSIONS <br />/}D (fQ\J,de 7~a:r;erJ <br />Uuo...fu L~ lUtE ~ D ILCdi. <br /> <br />~t'L -(J4c SiAr-5v D~ C/U LEu s ~{L <br /> <br />SCOPE OF WORK .-:- ___ ~;1 <br />E:. me. R. Ct u~ '~n I€c I/JJ~ (!/eA-~uf..e <br /> <br />tJu 2.1 ,j~ <br /> <br />.J-!UfLlJ..rC,A wE" Cc-e,(L Le <br /> <br />Does the Scope of Work change the pre-disaster conditions at the site? <br />Special Considerations issues included? DYes r8I No <br />Is there insurance coverage on this facility?D Yes ~ No <br />PROJECT COST <br /> <br />D Yes No <br />Hazard Mitigation proposal included D Yes ~ No <br /> <br />I <br /> <br /> <br />NARRATIVE <br />T-c.,/, c.e (!)l.J -1n1 e <br /> <br />QUANTITY IUNIT <br /> <br />UNIT PRICE <br /> <br />COST <br /> <br />ITEM CODE <br /> <br />LS. <br /> <br />l&, 1, 5';V <br /> <br /> <br /> <br />TOTAL COST <br /> <br />. s 2.... <br /> <br />REPLACES ALL PREVIOUS EDITIONS. <br />