FORM # AZ PA 204-19
SHEET OF SHEETS
ARIZONA DIVISION OF EMERGENCY MANAGEMENT
DATE
PRELIMINARY DAMAGE ASSESSMENT SITE SUMMARY
PART I — APPLICANT INFORMATION
COUNTY NAME OF APPLICANT NAME OF LOCAL CONTACT PHONE NO.
POPULATION TOTAL BUDGET MAINTENANCE BUDGET DATE FY BEGINS
Approved $
Balance $
Approved $
Balance $
PART II — COST ESTIMATE - SUMMARY (COMPLETE SITE ESTIMATE BEFORE SUMMARIZING BELOW)
CATE- NO. OF TYPES OF DAMAGE COST ESTIMATE POTENTIAL LOCAL FUNDS FOR RECOVERY
GORY SITES FUND/ACCOUNT AVAILABLE BALANCE
TOTAL TOTAL
PART III — DISASTER IMPACTS (USE SEPARATE SHEETS IF NECESSARY)
A. GENERAL IMPACT:
1. Identify and describe damages which constitute a health and/or safety hazard to the general public.
2. Population adversely affected directly or indirectly by the loss of public facilities or damages.
3. What economic activities are adversely affected by the loss of public facilities or damages?
B. RESPONSE CAPABILITY: Can the applicant respond and recover from the damages quickly and without degradation of public services? Describe.
C. IMPACT ON PUBLIC SERVICES IF DECLARATION IS NOT MADE: e.g., Deferral of permanent repairs, impact on ongoing services and capital
improvements, etc. Describe.
NAME OF INSPECTOR AGENCY PHONE NO.
