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i <br />40 <br />® - O.M.B. No. 7067-0151 <br />M FEDERAL EMERGENCY MANAGEMENT AGENCY <br />PROJECT WORKSHEET P w \1 Expires Ap6I 30. 2001 <br />j PAPERWORK BURDEN DISCLOSURE NOTICE <br />i Public reporting burden for this form is estimated to average 30 minutes. lite 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 collectton of information unless a valid OMB control number is displayed in the upper right <br />corner of the forms. Send comments regarding the accuracy of the burden estimate and any suggestions for reducing the burden to: <br />Informaton <br />Collections Management, Federal Emergency Management Ag <br />iency, 500 C Street SW, Washington, DC 20472, <br />C <br />Paperwork Reduction Project (3067- 0151). NOTE: Do not stand your completed form to this address. <br />f DATE CATEGORY <br />DECLARATION NO. PROJECT NO. FIPS NO. <br />! pL7 .DR.L`� Za9- A occl- qS o�,,t-- �;o iZ" I ' q4 <br />FEMA- WORK COMPLETE AS OF: <br />DAMAGED FACILITY <br />&A —>i 1�—lr_`71ON COUNTY <br />APPLICANT <br />I� <br />�k>tA s/0( LATITUDE LONGITUDE <br />i LOCATION <br />DAMAGE DESCRIPTION AND DIMENSIONS �Orm SLG V C6 r1 �CY�IL�!!C(� 1z el <br />tt�I M"1/�a� `i�,Da3C WA, -,.h ul-'ll �cu.tr oonyartcal <br />Y T/Lk c y u . za /o = 9, a a C11. <br />1 <br />t <br />SCOPE OF WORK �LaY� Z�ly REW,(Ql� 1-0 COO <br />C�„�AC,y 1 CtM. A DOt R r iAI Sat�t� MAc �IA� �� PP <br />�rt�s-s�t�/�L�✓a-^�Lt�! 5��t�4�rt o►.�, � var #t <br />1✓L F'CbT14A— <br />' 1061c� . �RYKt N� <br />I <br />i <br />Does the Scope of Work change the pre -disaster conditions at the site? <br />Special Considerations issues included? ® Yes No <br />Is there insurance coverage on this facili[y?❑ Yes No <br />r7PR:E:PA�REO8Y: t u <br />NARRATIVE <br />0 <br />El Yes ©-No <br />Hazard Mitigation proposal included Q Yes 0 No <br />COS#/L,5 <br />T UNIT PRICE COST <br />*113' C -V A I (.Z 4,8, <br />#q,,,n97. c0- 8 Jo n97. °— <br />REPLACES ALL PRSVIOU` `nITIONS. <br />TOTAL COST <br />