Attch-5 Debris Recovery Statement (DPW).pdf

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Roof Installation Requirement W91QF4-26-B-A002
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IFB_W91QF426IFB002_Roof
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This is a Debris Recovery Statement template for post-demolition and construction projects, issued by the Kansas Department of Health and Environment (Form Rev: 10 February 2023).

The form requires contractors to document the disposition of all materials generated during demolition or construction activities, with a mandatory minimum recycling/reuse rate of 60% of total waste. Contractors must complete a detailed material tracking table identifying specific waste streams—including asphalt, brick, cardboard, carpet, concrete, drywall, metal, pallets, plastics, plant debris, roofing materials, and wood (both clean and treated)—and designate each material as reused, recycled, or disposed. For each material category, contractors must identify the specific facility or service provider and document the weight in tons. Materials reused on-site require description of the reuse application, and salvaged materials from deconstruction should be designated as reuse. The form requires supporting documentation such as receipts, gate tags, or verification records from facilities and service providers. The Material Generation Synopsis section requires calculation of total materials generated, total materials disposed, total materials salvaged/reused/recycled, and the overall percentage of materials recycled or reused. The form references the Kansas Department of Health and Environment's Builders Guide to Reuse and Recycling available at https://www.kdhe.ks.gov/710/Waste-Reduction-Grant-Guidelines-Forms for jobsite material recovery assistance.

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Form Rev: 10 February 2023

DEBRIS RECOVERY STATEMENT – Post Demolition/Construction

Project Address: _____________________________________ Contractor: _________________________________________ Date: ______________________________________________ Contact: ____________________________________________ Phone: _____________________________________ ________ Email: _____________________________________________ Project: ____________________________________________

Identify which materials were reused, recycled or disposed by completing the table below. You must recycle at least 60% of all waste generated. Check the designated box and provide the name of each facility or service provider and weight of materials. If the materials were reused on site, describe the reuse application under the facilities/service provider column. Salvaged materials from deconstruction should be designated as reuse. Attach copies of receipts, gate tags, or other verifying documentation.

Material Reuse Recycle Dispose Facility Service

Provider Weight (tons)

Asphalt Brick Cardboard Carpet Concrete Dirt/Clean Fill Dry Wall Metal Pallets Plastics Plant Debris Roofing - asphalt composition shingle, tile, wood shake, tar or gravel

Wood - clean Wood - treated Other Other

MATERIAL GENERATION SYNOPSIS

A. Total tons of materials generated for the project: _____________ B. Total tons of materials disposed (not recycled): _____________ C. Total tons of materials salvaged, reused, or recycled: _____________ D. Percentage of materials recycled/reused (divide C by A):_____________ %

For assistance in recovering materials at the jobsite, visit the following website for a Builders Guide to Reuse and Recycling for the Kansas Department of Health and Environment.

https://www.kdhe.ks.gov/710/Waste-Reduction-Grant-Guidelines-Forms

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Date:
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Project:
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A Total tons of materials generated for the project:
B Total tons of materials disposed not recycled:
C Total tons of materials salvaged reused or recycled:
D Percentage of materials recycledreused divide C by A:
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