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FEDERAL EMERGENCY MANAGEMENT AGENCY <br />NOTICE OF INTEREST IN APPLYING <br />FOR FEDERAL DISASTER ASSISTANCE O.M.B. NO. 3067-0033 <br />PAPERWORK BURDEN DISCLOSURE NOTICE <br />Public reporting burden for this form is estimated to average 30 minutes per response. This includes the time for reviewing instructions, searching <br />existing data sources, gathering and maintaining the data needed, completing, reviewing, and submitting the form. Send comments regarding this <br />burden estimate or any aspect of this requirement, including suggestions for reducing this burden to: Information Collections Management, <br />Federal Emergency Management Agency, 500 C Street, SW, Washington, D.C. 20472; and to the Once of Management and Budget, Paperwork <br />Reduction Project (3067 -0033), Washington D.C. 20503 <br />NOTE: Complete form and turn Into the Governor's Authorized Representative at the Applicants Briefing for this major disaster, but <br />not later than 30 days after your county Is designated eligible for Public Assistance. <br />DECLARATION NUMBER <br />FEMA•MN DR-1225 <br />PROJECT APPLICATION NUMBER <br />(For Agency Use Only - FIPS 11) <br />NOI DATE <br />37.. /y /r /g997 <br />The purpose of this form is to list damages to property and facilities so that inspectors may be appropriately assigned for formal survey. <br />REQUIREMENTS <br />DEBRIS CLEARANCE <br />[ ] On Public Roads & Streets <br />[ ] Other Public Property <br />[ ] Private Property (When <br />[ ] Structure Demolition <br />C. ROAD SYSTEM <br />[ ] Roads 1 1 Street <br />[ ] Bridges [ ] Culverts <br />E. BUILDING AND EQUIPMENT <br />[ ] Buildings and Equipment <br />[ ] Supplies or Inventory <br />[ ] Vehicles or other equipment <br />[ ] Transportation System <br />G. OTHER (Not in the above <br />*Indicate type facility <br />FOR EMERGENCY <br />including ROW <br />undertaken by local gov't forces) <br />[ ] Control Traffic <br />[ ]* <br />DAMAGE SURVEYS <br />B. PROTECTIVE <br />[ ] Life and Safety <br />[ ] Property <br />1 1 Health <br />[ ] Stream/Drainage <br />D. WATER CONTROL <br />[ ] Dikes <br />[ ] Drainage <br />[ ] Levees <br />•'UBLIC UTILITY SYSTEMS <br />[ ] Water <br />1 1 Storm Drainage <br />[ ] * <br />MEASURES <br />Channels <br />FACILITIES <br />[ ] Dams <br />Channels [ ] Irrigation Works <br />[ ] <br />categories) [ ] Park <br />[ ] Sanitary Sewage <br />[ ] Light/Power <br />Facilities [ ] Recreational Facilities <br />NAME OF POLITICAL SUBDIVISION OR ELIGIBLE - <br />APPLICANT (NOTE: If Private Non -Profit. provide name of <br />facility and/or Non -Profit Owner) <br />PRIVATE NON- PROFIT <br />E 1 YES pd NO <br />COUNTY <br />Q <br />Aix re y <br />REPRESENTATIVE I �� <br />JoEG /E/.o.�/Ie.✓ <br />REPRESENTATIVE2 <br />11 74%(7 /4A/ 74-C <br />BUSINESS ADDRESS (INCLUDE ZIP CODE) - <br />cis- &. C /e /e ea--.0. •-' --a <br />Li ICc. C.. -414 atd rri /7 <br />ATTENTION: <br />"/oE[ .r.✓Ja <br />BUSINESS TELEPHONE # (Include area code & Extension) <br />(6'57) YOPY–z /77 <br />TELEPHONE # (Include area code and extension) <br />(43a0) 3S5-4'/G7 <br />( /77 Z/717/6 <br />Page 114 <br />