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Home My WebLink AboutA015 - Groundwater Hazard Statement REAL ESTATE TRANSFER - (iROUNUWATI;R HAZARD STATEMENT I'Icase read the filing instructions on the reverse side BEFORE completing this form. PART I - TO BE COMPLETED BY 'TRANSFEROR (Please "type or Print Legibly) TRANSFEROR Name H & F Builders Partnership Address 105 S. 16th Street Ames Iowa 50010 Horn er am t5 reel ur�FR ---------------------------(`ity.Town ur(.�).------- �ta�e TRANSFEREE Name Bentwood Subdivision Fourth Addition Address N—um ear—fir Streetor — -- —lily. own orp.�---- tale Zip Address of Property Transferred—Fl _ uor er an ,trcet or�k Z�iy,I'u�wi,or t'a'). .late Lip Legal Description of Property Outlot "Z" in Bentwood Subdivision, Third Addition, an Official Replat, Ames, Iowa 1. Wells(check one) 9 There are no known wells situated on this property. ❑ There is a well or wells situated on this property. The type(s), location(s) and legal status are stated below. 2. Solid Waste Disposal (check one) Ig There is no known solid waste disposal site on this property. ❑ There is a solid waste disposal site on this property,but no notice has been received from the Department of Natural Resources that the site is deemed to be potentially hazardous. LI There is a solid waste disposal site on this property which has been deemed to be potentially hazardous by the Department of Natural Resources. The location(s)of the site(s) is stated below. 3. 11azardo6s Wastes(check one) " LX There is no known hazardous waste on this property. ❑ There is hazardous waste on this property and it is being managed in accordance with Department of Natt,ral Resources rules. 4. Underground Storage'Tanks(check one) r LXThere are no known underground storap , tanks on this properly. (Note exclusions such as small farm and residential motor fuel tanks, most heating oil tanks, cisterns and septic tanks, in instructions.) ❑ There is an underground storage tank or tanks on this property. The type(s), size(s)and any known substance(s)contained are described below. 5. Private Burial Site(check one) IXThere are no known private burial sites on this property. ❑ There is a private burial site on this property. The location(s)of the size(s) is stated below. The known identifying information of the decedent is stated below. Information, if any, required by statements checked above: Attachment for Additional Information? Y/N If so, number of'pages I HEREBY DECLARE 7' IAT°I'HE INFORMATION CONTAINED IN PART 1 OF'1'111S STATEMENT IS TRUE AND CORRECT Signature: -_-_ I'elcphone Number: _(�l`j_ Z7 7 Y� 15�7 -------------------------------------------------------------------------------------------------------------------------------------------------------------------------- 1'AR'1' If -'1'O 13E C0M1'1,1?'1'EU 13l' RECORDER _Date of Instrument - -------_��-��__ _------- --- Book/I.U. I abe/L U.O O Date of Recording_ ity( r Township �ej - Deed Contract I I Connty --------------------------------------------------- _ _ ---- — DNR form(July 99) Fll,l? WITII RECORDER 542-0960 (See Instruction //6) . a INSTRUCTIONS FOR CO�iI'I.P:"1'INC GROl1NIriVA"I'N it IIAZARD STATEMENT The transferor of'real property is required to complete Part I of this 3. Hazardous Wastes - "Hazardous waste" is defined in Iowa form. The purpose of the statement is to satisfy legal requirements Code section 45511.411, 567--141.2 (45511), i.A.C., and federal fur filing instruments of- conveyance of real property with the regulations referenced therein. It is generally defined as waste county recorder (Iowa Code Section 558.69). The Department of that poses it threat to human health or the environment. It Natural Resources does not approve or disapprove of property includes wastes which are ignitable, corrosive, toxic, explosive, transfers based on these statements. The statement must be signed violently reactive, or specifically listed as hazardous in the Code by one of the persons transferring the property interest or that of* Federal Regulations (40 CFR 261). EXCLUDED are Pei-soil's agent. An agent signing this furor represents the household wastes, agricultural wastes returned to the soil as inf'orniation from transferor to be correct. fertilizers or soil conditioners, agricultural chemicals applied or disposed of by a farmer in accordance with the manufacturer's For the most part the information requested is clear (name, instructions, triple-rinsed agricultural chemical containers address, etc.). One statement under each of the numbered items disposed of by farmers (where the rinsate is used as makeup (1, 2, 3, 4 and 5) must be checked, and if one or more of- the water in the tankmix and applied at appropriate rates), and other statements checked requires the transferor to provide additional specific materials. Persons are legally required to be aware of infirrmation, that information is to be provided in part 1. Relate the hazardous waste laws. additional information to the specific category of facility (well, etc.) by numbering it with the corresponding number (1, 2, 3. 4, 4. Underground Storage "Tanks - "Underground storage tank" 5). if additional space is needed, type or print it legibly on a means one or a combination of tanks, including underground separate sheet or sheets, complete the statements at the end of-fart piping connected to the tanks, used to contain an accumulation of i and attach the additional information to all copies of the firrn►. regulated substances, and the volume of which is 10 percent or When describing the location of' a facility on the property, be more beneath the surface of the ground. "Regulated substances" reasonably precise, such as a specific distance and general include petroleum products and hazardous or toxic materials direction from a landmark or corner of the property. A identified in 567--135.2(455B), I.A.C. Underground storage professional survey is not necessary. The following definitions are tank does not include: for use in completing the firrn►. a. Farm or residential tanks of 1,100 gallons or less capacity I. Wells - A "well" is any excavation that Is drilled, cored, hored, used tier storing motor fuel for noncommercial purposes. But augered, washed, driven, dug, jetted or olherwise constructed for See 45513.473(4)) accessing groundwater or (irr diverting surface water into the b. `yanks used for storing heating oil for consumptive use on the ground, including abandoned wells. "Well" does not include an premises where stored. open ditch of drainage tiles which discharge to the surface, c. Residential septic tanks. d. Pipeline facilities regulated by state or federal law. Tl"a well is an"abandoned well"or an "agricultural drainage well," e. A surface impoundment, pit pond,or lagoon. this must be identified and the status of the well with respect to f. A storm water or wastewater collection system. Iowa Code sections 45513.190 and 159.29, respectively, must be g. A Ilow-through process tank. stated. Ali "abandoned well" is a well no longer in use or in such It. A liquid tap or associated gathering lines directly related to state of disrepair that•continued use is unsafe or impracticable. oil or gas production and gathering operalioms.. Abandoned wells are to be properly plugged in accordance with i. A tank in an underground area such as a basement or mine, if chapter 39 of" the rules of the Department of Natural Resources. the tank is on or above the surface of the floor. (567 Iow;vAdmimislrative Cade, Chapter 39) j. Pipes connected to the above exclusions. *An "agricultural drainage well" is a well constructed fix the "'Tank type" means the material of construction (steel, fiberglass purpose of draining, or which drains, water from agricultural land reinforced plastic [FRP], or other [specify]), and any internal or to an aquifer(underground), excluding drainage tile intakes which external protection such as a protective coating or wrapping, or outlet to the surface. Agricultural drainage wells are required to cathodic protection. be registered with the department by September 30, 1988, and the owner of" the well and of the land drained by the well are to Identify the capacity in gallons and the substance stored in each develop a plan proposing alternatives to the use of the well by lank. July I, 1998 (See Iowa Code Section 159.29.) 5. Private Burial Sites - "Private Burial Site" means one or 2. Solid Waste - "Solid waste" means garbage, refuse, rubbish more graves containing human remains. For each site the and other similar discarded solid or semisolid material. it does not transferor shall state the location of the site. For each decedent include dirt, stone,brick, or similar inorganic material used fur till, buried on the property the transferor shall state all known as long as no other solid waste is included. See 567--100.2(45513), identifying information of that decedent including name, date of Iowa Administrative Code (I.A.C.) for further definitions. A dealt, and dale of'birtli. "disposal site" is any area on the property on, in, or under which solid waste has been disposed, whether or not the disposal is or 6. Filing - The original of this form must be presented to the was regulated by the department. county recorder when the document to be recorded is filed. "The Recorder shall forward the original to the transferee when the If (lie transferor or agent has not received notice from the recorded instuumlent is returned. The recorder is not required to Department of Natural Resources that the disposal site has been keep any copies. deemed to be potentially hazardous, there is no duty to inquire to the depai(meat. *Note The land application of sludges or soils resulting from the remediation of underground storage tank releases accomplished in CD compliance with Department of Natural Resources rules without a permit is not required to be reported as the disposal of solid waste CD or hazardous waste. (See Iowa Code Section 558.69) i O OD DNR f'orn(July 99) 543-0960