HomeMy WebLinkAboutPlease_DocuSign_Recycling_Form_-_BLDG-1978-2DocuSign Envelope ID: 5CB82389-04EA-42FF-B596-A3DC95D199DF
CONSTRUCTION & DEMOLITION RECYCLING PLAN and DISPOSAL REPORT
City of San Luis Obispo Utilities Department • 879 Morro Street, San Luis Obispo, CA 93401 • 805-781-7215
Please read this form carefully. The goal is to clearly document that you have recycled a minimum of 65% of C&D materials, per California State regulations.
Prior to Project: Completely fill out Section 1 and Section 2 (if applicable).
Section 1: To be completed by all Building Permit Applicants
Application Number:
Site Address:
Type of Project:
BLD-1978-2021
3535 Hiquera Street
Tenant Improvement - Cannabis Retail
Owner's Name:
Contractor's Name:
Square Footage:
Stephan Kennedy
4829
Owner'
Contractor's Phone:
Estimated Project Cost:
$1,000,000
Using a Certified Roll -Off Company exclusively? Y / N
Self -Hauling? Y / N YES
Estimated Fine for Failure to Comply (2% of total EPC):
$4,000
IF YES, WHICH ONE?
IF YES, COMPLETE SECTION 2.
Applicant's Name: (Printed) (Signed) Date:
Stephan Kennedy 7/12/2022
Section 2: To be completed ifself-hauling.
If self -ha uling, please list the recycling facilities where the waste will be taken.
Concrete and Asphalt:
Wood: Santa Maria Transfer station
Cardboard: Santa Maria Transfer station
Gator Crushing and Recycling
or Chicago Grade and landfill - Atascadero
or Chicago Grade and landfill - Atascadero
Drywall: Santa Maria Transfer station
Metals: Santa Maria Transfer station
Other: Santa Maria Transfer station
or Chicago Grade and landfill - Atascadero
or Chicago Grade and landfill - Atascadero
I understand that I must produce receipts listing tonnage of all materials
leaving the project site, regardless of destination or method of removal.
I certify that I will communicate this plan and requirements to all
contractors and other personnel who may be involved in disposal of
materials from this project, and inform them that they must provide
receipts for all recycling and trash disposal.
The final permit and all waste receipts must be presented prior to final
sign off. I understand that failure to do so may incur a penalty of 2% of
total project valuation.
7/13/2022
(Sign) (Date)
• ALL TONNAGE LEAVING SITE MUST BE ACCOUNTED FOR
ON THIS FORM
• FAILURE TO RECYCLE AT LEAST 65% OF MATERIALS CAN
RESULT IN A PENALTY OF 2% OF PROJECT VALUATION
For Utilities Office Use Only
Plan Approved:
Reviewed/Approved by:
Project Exempt:
Plan Denied:
Date:
DocuSign Envelope ID: 5CB82389-04EA-42FF-B596-A3DC95D199DF
CONSTRUCTION & DEMOLITION RECYCLING PLAN and DISPOSAL REPORT
Upon Completion of Project: Submit receipts for sign off.
Step 1: Gather waste receipts listing tonnage for all materials that left the project site. Receipts must list tonnage as "recycled" or "disposed". Note
that "Mixed Recycling" receipts qualify as 70% recycling and 30% trash.
Step 2: Bring all receipts and final permit to 879 Morro for sign off. You may first call 781-7215 to verify that someone will be available for sign
off.
For Utilities Office Use Only
AFTER CONSTRUCTION (Actual Tonnage)
TONS
Actual tonnage of off -site RECYCLED
Actual tonnage of on -site REUSED
Actual tonnage of BURIED TRASH/LANDFILL
Actual tonnage of "OTHER" waste
Actual TOTAL tonnage of construction waste
Percentage of Materials Recycled & Reused: %
Notes
Goal Achieved:
Penal Paid:
Substantial Compliance:
Reviewed/Approved by:
Goal Not Achieved:
Date: