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U.S.DEPARTMENT OF HOMELAND SEC:URITY.... Cl�tt:]i No I660-0017 <br /> Ff,DI,:RA( E°MERG(NC:Y MANA04 MLNI AC,rt NC:'t ISxgxi6 sCavta6srt .3[)i)'. <br /> WORKSHEET <br /> RAPEI2V6=ORK Bt ElN DISCLOSURE NOTICE. <br /> PUb n;pfrtimg lanT&Tt for th',roan is estimated to average 90 minutes Nr reslxnvsc Birrden means the time,eft'asrt and financial resotrrecs <br /> e�pen led ta}Tn r a a s t sera gate,mu rata ra,cGavlcse,car to I rova le as l artea tyota tca s. ou may'seiu corranerds tetrar&irg the Wrtlen estimate or aany' <br /> aslsect of the collechcm,includiag suggestions Erre rettarcnag the burden to:Inforarata n Colleetions Maa><agenaent,U.S.Llegt tmentof flomb-latid <br /> Sectrrlty,Federal EmeTgency Management Agency„500 C'Street SW Washington,t)('20471,Paperwork Reelncnon Ilvi'cct(OMB Control Mian cr <br /> la t B-tlt 17Y° 1 an ate na:i r grured t a aesptntai to this o lection of irifanrtatioji iuiless ar valid 6NIB number atapeuTs in.Che utter nghl corner of dis <br /> tone. NOTES Do not send yomw completed questtonn airs to dais address- <br /> -T=RY€R4JEGT NO. 1'A 3U NCl° DATE: GA3 EGL 1�Y <br /> HEMA° Dft <br /> DAMAGED FACILITY WORK COMPVtIt AS OF <br /> �.a <br /> APPLICANT COUNtY <br /> LOCATION IA11fWE iCINCtlIWE <br /> DAMAGE DESCRIPTION AND DIMENSIONS <br /> Does the Scope of Work change the pre-disaster conditions at the site`' Yes No <br /> Special Cransidevations issues included? Yes No EIa?ard Nfitigxation proposal rncludecd` I es rj No <br /> Is these insurance coverage on this facility"Dyes Nes <br /> PROJECT COST <br /> ITEM CODE NARRATIVE QUANTITYIUNIT UNIT PRICE CYST <br /> .}3',f`!It f i@�)}"2.CJ t,sS{42f>r 3>1r43S1 r43S1 r43S1 r43S1 r43S1 r43S1 r43 S1 r43S1?"431 r421 f%1$j5>a�{.. £, <br /> rzS.2i,{at r2FE C<>Srr{t>,r���r$�JSi�,S��Sa it��tr 2iizs£2�aC2�f222,�£2�aC2�f222,�£2�aC2�f222,�£2�aC2�f}22,�E2"'r+�lfi r,x�i�stlP�tf j f j"i,s,3S324ttiS �i. <br /> �i{ i���� jfia�+art��lllli����,�ft roTaLc€sr �s <br /> PREPARED ESr'..... TITLE _. SIGNAIURF <br /> APPLICANT REP. TITLE. SIGNATURE <br /> HEMA Ener)90 91,FEB 00 REPLACES ALL PRENAOUS EDITIONS.. <br />