PublicDamages+OtherCostsSurvey_2.1.21

OMB CONTROL NUMBER: 0710-0017

OMB EXPIRATION DATE: XX/XX/XXXX

AGENCY DISCLOSURE NOTICE

The public reporting burden for this collection of information, 0710-0017, is estimated to average 20 minutes per survey, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding the burden estimate or burden reduction suggestions to the Department of Defense, Washington Headquarters Services, at [email protected]. Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number.

PUBLIC DAMAGES AND OTHER COSTS

1. Name of Governmental Entity: _______________________________

2. Agency: ______________________________________

3. Phone Number: ______________________________________

4. Dates of Flooding/

Coastal Storm: ______________________________________

5. Source(s) of Flooding: ______________________________________

6. In the table below list the damages that occurred to public property in your jurisdiction as a result of the (date) flood.

Type of Property	$ Damage	Primary Cause of Damage (inundation, wave, erosion, etc.)
Buildings	$____________
Equipment	$____________
Vehicles	$____________
Supplies	$____________
Streets, highways, roads	$____________
Water supply system plant and equipment distribution system	$____________
Sewage system plant and equipment distribution system	$____________
Drainage system	$____________
Bridges	$____________
Docks	$____________
Marinas	$____________
Boardwalks	$____________
Parks	$____________
Other	$____________

7. Please list any other public cost that resulted from the flooding in your jurisdiction.

Type of Costs	$ Costs	Volunteer (unpaid hours)
Emergency operations and floodfighting	$________________________	________ Hours
Police protection	$________________________	________ Hours
Additional costs of water supply	$________________________	________ Hours
Additional costs of sewage treatment	$________________________	________ Hours
Additional costs of flood cleanup	$________________________	________ Hours
Additional costs of trash collection and disposal	$________________________	________ Hours
Replacement of business records	$________________________	________ Hours
Repairs to levee, sand dunes, or other flood or coastal protection	$________________________	________ Hours
Cleanup of hazard waste	$________________________	________ Hours
Other costs	$________________________	________ Hours
Total	$________________________	________ Hours

8. Please describe any harmful public health and other environmental effects that flooding may have caused by inundation of landfills, sewage treatment plants, or other hazardous waste sites.

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

If you had a damaged sewage treatment facility in the most recent flood, please answer questions 9-13. (If not, skip to question 14.)

9. What is the capacity of the damage facility in gallons per day?

_______________ Gallons per Day

10. What is the estimated replacement cost of the plant?

$_________________

11. How high did the water get above the lowest ground elevation of the plant?

_____________ FEET

12. What was the repair cost to the plant?

$_______________

13. How many days was the plant not operating because of the flood damage?

________________ DAYS

If you had a damaged WATER treatment facility in the most recent flood, please answer questions 9-13. (If not, the survey is complete.)

14. What is the capacity of the damage facility in gallons per day?

_______________ Gallons per Day

15. What is the estimated replacement cost of the plant?

$_________________

16. How high did the water get above the lowest ground elevation of the plant?

_____________ FEET

17. What was the repair cost to the plant?

$_______________

18. How many days was the plant not operating because of the flood damage?

________________ DAYS