HomeMy WebLinkAboutA012 - Groundwater Hazard Statement REAL ESTATE TRANSFER - GROUNDWA"fI:R HAZARD STATEMENT
]'lease read the filing instructions on the reverse side ttEFOttts completing tl►is form.
PART I - TO BE. COMPLETED BY TRANSFEROR
(Please Type or Print Legibly)
TRANSFEROR Name SCa 7—
L7 • /L �/V[�L
Address L/:?—o S1 /
Unwl lH all,'lleel of .1 y. awn r late
NTRANSFEREE Name—
Address
Address
ulll el and sticel..r ItIt City.I uw11 or P.O. statc: Lip
Address of Property Transferred—1 Q /
m ter an elect a Itit �City,Town,ur P.O. - Wale .y.
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r
Legal Description of Property
1. W Its(check one)
9here are no known wells situated on this property.
0 There is a well or wells situated on this property. The typc(s), localion(s) and legal status are stated below.
2. Solid Waste Disposal (checic one)
]'here is no known solid waste disposal site on this property.
0 'here 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 dccmed to be potentially hazardous.
0 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 sile(s) is stated below.
3. II.zardous Wastes(cheelc one)
'there is no known hazardous waste on this property.
O there is hazardous waste on this property and it is being managed in accordance with Department of Natural Resources rules.
4. Underground Storage Tanks(cl►eck one)
t There are no known underground storage tanks on this property. (Note exclusions such as small farm and residential motor fuel tanks,
most heating oil tanks,cisterns and septic tanks, in instructions.)
Q There is an underground storage tank or tanks on this property. The typc(s),size(s) and any known substance(s)contained are describe.
below.
5. Pjivate Burial Site(check one)
jam( There are no known private burial sites on this property.
O There is a private burial site on this property. The locations) of the site(s) is stated below. The known idcntifying.information of the
decedent is stated below.
Information, if any, required by statements checked above:
Attachment for Additional It tion? Y/ If so, number of pages
I IIEREMY DECI t. 'I'll 'I : I FORMA' N CONTAINED IN PART 1 OF TIIIS STATEMENT IS TRUE AND CORRECT
Signature: Telephone Numbcr:
Ialli c.,w or •l'lll
-------------------------------- ---------------------;------------------ ------------;---;---------------------- ----------------------------- -----------------------
I ART II TO BE COMPLETED BY RECORDER 00 _ 0 Ar+5 5 O
Date of Instrument _ �v l "4A-B- --P g,
Date of Recordin[,g s—a —M
ity r"Township__
Dec,x Contract 0 County Str
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DNR form(July 99) FILE WITH RECORDER 542-0960
(Sec Instruction 116)
INSTRUCTIONS FOR COMPLETING GROUNDWATER IiA'LARD STATEMENT
The transferor of real property is required to complete Part i of this 3. Idazardous Wastes - "Hazardous waste" is defined in Iowa
form. The purpose of the statement is to satisfy legal requirements Code section 45513.411. 567--141.2 (455i3), i.A.C., and federal
for filing inslr nicnis 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 a threat to human hcallh or the environment. it
Natural Resources does not approve or disapprove of property includes wastes which arc 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 properly interest or Ilia( of Federal Regulations (40 CFR 261). EXCLUDED arc
person's agent. An agent signing this form represents the household wastes, agricultural wastes returned to the soil as
information 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, ctc.). One statement under cacti of the numbered items disposed of by famicrs (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
stalcmcnts checked requires the transfcror to provide additional specific materials. Persons arc legally required to be aware of
information, that information is to be provided in part 1. Relate the hazardous waste laws.
additional information to the specific category of facility (well,
Cie.) 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 Part piping connected to the tanks, used to contain an accumulation of
i and attach the additional information to all copies of the form. regulated substances, and the volume of which is 10 percent or
When describing the location of a facility on the property, be more beneath (he 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(4558), I.A.C. Underground storage
professional survey is not necessary. The following definitions are tank does not include:
for use in completing the form.
a. Farnr or residential tanks of 1,100 gallons or less capacity
1. Wells- A "well" is any excavation that is drilled, cored, bored, used for storing motor fuel for noncommercial purposes. But
j angered, washed, driven, dug,jetted or otherwise constructed for See 455B.473(4))
accessing groundwater or for diverting surface water into the b. 'Tanks used for storing heating oil for consumptive use on the
ground, including abandoned wells. "Well" does not include an premises where stored.
open ditch or drainage tiles which discharge to (lie surface. c. Residential septic tanks.
d. Pipeline facilities regulated by state or federal law.
If 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 flow-through process tank.
staled. An "abandoned well" is a well no longer in use or in such h. A liquid trap or associated gathering lines directly related to
state of disrepair that continued use is unsafe or impracticable. oil or gas production and gathering operations.
Abandoned wells arc to be properly plugged in accordance with i. A tank in an underground area such as a bascment 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 Iowa Administrative Code, Chapter 39) j. Pipes connected to the above exclusions.
An "agricultural drainage 'well" is a well constructed for the "Tank type" means the material of construction (steel, fiberglass
purpose of draining, or which drains, water from agricultural land reinforced plastic [rRP], or other (specify)), and any'inlernal or
to an aquifer(underground), excluding drainage the intakes which external protection such as a protective coating or wrapping, or
outlet to the surface. Agricultural drainage wells arc 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 arc to identify the capacity in gallons and the substance stored in each
develop a plan proposing alternatives to the use of the well by tank.
July I, 1998 (Sec lows Code Section 159.29.)
S. Private Burial Sites - "Private Burial Site" mcans one or
2. Solid Waste - "Solid waste" mcans garhage, refuse, rubbish more graves containing human remains. For each site the
and other similar discarded solid or sernisolid material. it flocs not transfcror shall state the location of the site. For each decedent
include dirt,stone,brick,or similar inorganic material used for fill, buried on the property the transfcror shall state all known
as long as no other solid waste is included. Sec 567--100.2(455B), identifying information of that decedent including name, date of
Iowa Administrative Code (I.A.C.) for further dcfnitions. A death,and(late of birth.
"disposal site" is any area on the property on, in, or under which
solid waste has been disposed, whclhcr 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 the transfcror or agent has not received notice from the recorded instrument is returned. The recorder is not required to
Department of Natural Resources that the disposal site has been keep any topics.
deemed to be potentially hazardous, there is no duty to inquire to
the department.
"Note The land application of sludges or soils resulting from the AO
remediation of underground storage tank releases accomplished in M
compliance with Department of Natural Resources rules without a
permit is not required to be reported as tluc disposal of solid waste
or hazardous waste. (See Iowa Code Section 558.69) KD
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DNR fornn(July 99) 5.13-0960