Form FEMA Form 010-0-9 FEMA Form 010-0-9 Request for the Site Inspection

DEPARTMENT OF HOMELAND SECURITY
FEDERAL EMERGENCY MANAGEMENT AGENCY

SITE CONTROL No.
(As Assigned)

REGISTRATION No.

O.M.B. No. 1660-0030
Expires January 31, 2014

REQUEST FOR THE SITE INSPECTION

PAPERWORK BURDEN DISCLOSURE NOTICE
Public reporting burden for this form is estimated to average 10 minutes per response. The burden estimate includes the time for reviewing instructions,
searching existing data sources, gathering and maintaining the needed data, and completing, reviewing, and submitting the form. This collection of information is
mandatory. You are not required to respond to this collection of information unless a valid OMB control number appears in the upper right corner of this form.
Send comments regarding the accuracy of the burden estimate and any suggestions for reducing this burden to: Information Collections Management,
Department of Homeland Security, Federal Emergency Management Agency, 500 C Street, SW, Washington, DC, 20472, Paperwork Reduction Project
(1660-0030). Please do not send your completed survey to the above address.
SITE INFORMATION

APPLICANT INFORMATION

SITE ADDRESS (House No. & Street Name)

NAME (Last, First, Middle Initial)

CITY AND STATE

COUNTY

NAME OF LANDOWNER

CURRENT ADDRESS (House No. & Street Name)
CITY AND STATE (Include Zip Code)

ADDRESS OF LANDOWNER
Primary:
Primary:
Alternate:

EGSS

Group

Private

Commercial

TEMPORARY HOUSING UNITS
REQUIRED (Check One)
1

2

Alternate:
MH
PM

3

TT
UFAS

SITE UTILITY INFORMATION (Completed by THP contact through inquiry to applicant)
RAMP
ADA/UFAS Compliant Unit

Natural
LP

MALE

FEMALE

None

Public
Well

YES
None

MALE

FEMALE

NO

Public
Septic

None

LANDOWNER AVAILABLE TO ACCOMPANY
INSPECTOR TO SITE
YES
NO

APPLICANT SIGNATURE

DATE

SITE DESCRIPTION AND DIRECTIONS (Form DFO to Site- attach map if necessary)

NAME OF SITE INSPECTOR (Assigned by DHOP's Chief)

DATE ASSIGNED
DATE
1st Choice

Within

Outside Restricted Zone

Flood Zone Map No.

2nd Choice

APPLICANT ACTIONS TO MAKE SITE ACCEPTABLE
Site Feasible

FF90-31, Landowner's Authorization/Ingress-Egress Agreement

FF90-96, Mobile Lease

Site Infeasible (State reason)
SIGNATURE OF SITE INSPECTOR

FEMA Form 010-0-9, FEB 06

DATE

APPLICANT NOTIFIED OF SITE DETERMINATION
Date:
By:

TIME