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Project Worksheet <br />Declaration No. Project No. FIPS No. Date: Category: <br />FEMA -Q!21, - DR- N CT G I V EH .. c( ZZ_ 1 CI it $. <br />Applicant: County: <br />INDIAN Iz-1Ve-9-- CO 9 -IV -- <br />Damaged Facility: Work complete as of <br />cH F.s ( DiJ IS <br />Location: Latitude: Longitude:- <br />9-t-, <br />ongitude: <br />ect-,Af l r- ?O i CrE� •4iTAC-HU-) Lid P <br />Damage Description & Dimensions: . <br />EeAGF; E�(JSIDf`{ <br />Scope of Work: — :�EU— ATTAGHEO — <br />OBTAtN, ()AL)L; PLA(_F SAND A i <br />CALM Stir✓ AS jAI)IC4TE0, DI,vte�lSloN-3 <br />MAY \1A2-`/ vJ ITF1 tH eACK StrtL <br />'DA50p bra L—VO- Lt= [_�20SIDt4 DAMAGES <br />Does the Scope of Work change the pre -disaster conditions at the site? ❑ Yes ❑ No <br />Special Considerations issues included? ❑ Yes ❑ No <br />Hazard Mitigation proposal included? ❑Yes ❑No <br />Is there insurance coverage on this facility? ❑Yes ❑ No <br />nydt '!gtnd I 141, Z8 C�If3 C 4# 13i9 5D` I <br />I <br />I <br />I • <br />I <br />I I <br />I <br />Total Cost $ 'L__L <br />Submitted By: <br />