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Dth-depth-sf-sy-cy-tonsnumber of items, etc.) DATE / Local Estimate of Cost $ 7 / PAGE Insurance Coverage Y/N $? OF PAGES Impact of Damage (public health & safety Essential / critical facilities population adversely affected Special Considerations (1) (see bottom of continuation sheet) YES $ 8 NO YES $ 9 $ NO YES NO 10 YES $ 11 NO YES $ 12 NO YES $ NO Special Considerations - Does the site have potential for: Hazardous Materials (HZ) - Unidentified drums, asbestos, tran.

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