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Home My WebLink AboutA009 - Real Estate Transfer - Groundwater Hazard Statement l REAL ESTATE TRANSFER - GROUNDWATER HAZARD STATEMENT Please read the filing instructions on the reverse side BEFORE completing this form. PART I - TO BE COMPLETED BY TRANSFEROR (Please Type or Print Legibly) Social Security No. �j _ '/7' TRANSFEROR Nar e,e_a � (�1� � (or Federal I.D. No.) 7� �?7�i Address 90 g !g�'od rica'�� /47&00 Number"and Street or RRR, _/ City,Town or P.O. State Zip TRANSFEREE Name On�--��S � r ' 'eG1 S-a d;Lk5/d/'�r FedeSocial ral I Security No.) �/� Address �'7C?S; � n/n Number and Street or RR City, own or P.O. State Zip Address of Property-_T_ransfered - Number and Street or RR City,Town or P.O. State Zip Legal Description of Property r77w,d -sag. IF s 1. Wells(che&o:ne) O'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) X'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. ❑ 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. Hazardous Wastes (check one) 'K 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 Natural Resources rules. 4. Underground Storage Tanks (check one) 'srThere 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.) ❑ 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. Information, if any, required by statements checked above: Attachment for Additional-lnformation? Y / N' If so; number of pages - - - I HEREBY DECLARE THAT THE INFORMATION CONTAINED IN PART I OF THIS STATEMENT IS TRUE. . AND CORP Signature: Telephone Number: (Transferor or ent) ( PART II -TO BE COMPLETED BY RECORDER Date of Instrument / ` 9A Book/I.D. Pa a/I.D.g � Date of Recording City r Township 4,)q e Deed o 0- P�af tS�or Contract .❑ County ----------------------------------------------------------7------------------------------- DNR form (JAN. 91) FILE WITH RECORDER 542-0960 (See Instructions, #5) INSTRUCTIONS FOR COMPLETING GROUNDWATER HAZARD STATEMENT The transferor of real property is. required to complete . 3.. Hazardous.Wastes - "Hazardous waste" is defined in Part I of this form. The purpose of the statement is to Iowa Code section 455B.411, 567-141.2 (455B), I.A.C., satisfy legal requirements for filing instruments of and federal'regulations referenced therein. It is generally conveyance of real property with the county recorder(Iowa defined as waste that poses a threat to human health or Code Section 558.69). The Department of Natural the environment. It includes wastes which are ignitable, Resources.does not approve or disapprove of property corrosive,toxic,explosive,violently reactive,orspecifically transfers based*on these statements. The statement must listed as hazardous in the Code of Federal Regulations be signed by one of the persons transferring the property (40 CFR 261). EXCLUDED are household wastes, interest or that person's agent.An agent signing.this form -agricultural wastes returned to the soil as fertilizers or soil represents the information from transferor to be correct. conditioners, agricultural chemicals applied or disposed of by a farmer in accordance. with the manufacturer's Fo`r'.the,most part the information requested is clear(name,, instructions,triple=rinsed agricultural chemical containers address, SSN, etc.). One statement under each of the disposed of by farmers (where the rinsate is used as numbered items (1, 2, 3 and 4) must be checked, and if makeup water in the tankmix and applied at appropriate one or more of the statements. checked requires the rates), and other specific materials. Persons are legally transferor to provide additional information, that informa- required to be aware of hazardous waste laws. tion is to be provided in Part 1. Relate the additional information to the specific category of facility (well, etc.) 4. Underground Storage Tanks - "Underground storage by numbering it with the corresponding number (1, 2, 3, tank" means one or a .combination of tanks, including 4). If additional space is needed, type-or print it legibly underground piping connected to the tanks, used to on a separate sheet or sheets, complete the statements contain an accumulation of regulated substances,and the at the end of Part I and attach,the additional information volume of which is 10 percent or more beneath the surface to all'icopies of the form. When describing the location 'of the ground. "Regulated substances" include petroleum of a facility on the property, be reasonably precise, such products and hazardous or toxic materials identified in as a specific distance and general direction from ea 567'135.2(45513), LKC. Underground storage tank does landmark or corner of the property. A professional survey not include: is not necessary. The following definitions are for use in a. Farm or residential tanks of 1,100 gallons or less completing the form. capacity used for storing motor fuel for noncom- mercial purposes. (But See 455B.473(4)) 1.Wells - A"well" is any excavation that is drilled, cored, b. Tanks used for storing heating oil for consumptive bored, augered, washed, driven, dug, jetted or otherwise use on the premises where stored. constructed for accessing groundwater or for diverting c. Residential septic tanks. surface water into the ground, including abandoned wells. d. Pipeline facilities regulated by state or federal law. "Well" does not include an open ditch or drainage tiles e. A surface impoundment, pit pond, or lagoon.- which discharge to the surface. f. A storm water or wastewater collection system. If a well is an"abandoned well"or an"agricultural drainage 'g• A flow-through process tank. well," this must be identified and the status of the well h. A liquid trap or associated gathering lines directly . with respect to Iowa Code sections 455B.190 and 159.29, related to oil or gas production and gathering respectively, must be stated. An "abandoned well" is a operations. well no longer in use or in such state of disrepair that L A tank in an underground area such as a basement continued use is unsafe or impracticable.Abandoned wells or mine, if the tank is on or above the surface of are to be properly plugged in accordance with chapter the floor. —39 of the--rules of the Department of Nafural Resources. j• Pipes connected to the above exclusions. (567 Iowa Administrative Code, Chapter 39) "Tank type" means the material of construction (steel, An "agricultural drainage well" is a well constructed for fiberglass reinforced plastic [FRP],or other.[specify]),and the purpose of draining, or which .drains, water from any internal or external protection ,such as a protective agricultural land to an aquifer (underground);excluding coating or wrapping, or cathodic protection. drainage the intakes which out to the surface. Identify the capacity in gallons and the substance stored Agricultural drainage wells are required to be registered in each tank. with the department by September 30,1988,and the owner of the well and of the land drained by the well are to develop 5. Filing - The original of this form must be presented a_plan proposing alternatives to the use of the well by to the county recorder when the document to be recorded July 1, 1994. (See 1991 Iowa Code Section 159.29.) is filed. If any of the four questions are answered in the affirmative so that explanations are required, a duplicate 2. Solid Waste - "Solid waste" means garbage, refuse, copy (or photocopy) of this form must be filed with the rubbish and other similar discarded solid or semisolid recorder. In cases where all four questions are answered material. It does not include dirt, stone, brick, or similar in the negative,this form will be forwarded by the recorder inorganic material used for fill, as long as no other solid to the transferee when the recorded instrument is returned. waste is included. See 567-100.2(455B), Iowa Adminis- If any of the questions are answered in the affirmative trative Code (I.A.C.) for further definitions. A "disposal so as to require an explanation, the recorder shall furnish site" is any area on the property on, in, or under which the original of this form to the transferee and forward the solid waste has been disposed,whether or not the disposal photocopy or other duplicate copy suitable for microfilm- is or was regulated by the department. ing to the department.The recorder is not required to keep If the transferor or agent has not received notice from any copies. the Department of Natural Resources that the disposal site has been 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 remediation of underground storage tank releases accomplished in compliance with Department of Natural Resources rules without a permit is not required to be reported as the disposal of solid waste or hazardous waste. (See 1991 Iowa Code Section 159.29) MiRecycledPaper Printed on CPF-86861 542-0960