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Home My WebLink AboutA007 - Real Estate Transfer - Groundwater Hazard Statement _ REAL ESTATE TRANSFER - GROUNDWATER HAZARD STATEMENT measc read the riling instructions on the reverse side BEFORE completing this form. PART I - TO BE COMPLETED BY TRANSFEROR (Please Type or Print Legibly) TRANSFEROR Nanie ".Q Address 6 l�� S OY l U Numb Lily.I own or 11.0. Slalp TRANSFEREE Name - �✓ � /l�L Address um cr an necl or tt ny, own or P.O. .talc Zip Address of Property Transferred NumberandS clorRR Lily. own,o .,.� lal , lip Legal Description of Property 1. Wells(check one) There arc no known wells situated on this property. ❑ There is a well or wells situated on (his property. The type(s), location(s)and legal status arc stated below. 2. Solid Waste Disposal (check one) 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 decnmed to be potentially hazardous by the Department of Natural Resources. The location(s)of the sitc(s) is stated below. 3. Ilazardous Wastes(check one) erc is no known hazardous waste on this property. 0 There is hazardous waste on (his property and it is being managed in accordance with Department of Natural Resources rules. 4. t Micrground Storage Tanks (check one) sere 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.) O There is an underground storage tank or tanks on this property. The type(s), size(s)and any known substance(s)contained are describe( below. 5. 'r'vate Burial Site'(clmeck one) Therc are no known private burial sites on this property. Tlmcre is a private burial site on this property. The location(s)of the sitc(s) is slated below. The known identifying.information of the decedent is stated below. Information, if any,required by statements checked above: Atlaclmmcnl for Additional nformation? Y/N if so umber of pages I HEREBY DECLARE' 1 AT' 1 E IN ' I CONTAINED IN PART 1 OF THIS STATEMENT IS TRUE AND C�OJ RREcr Signature: _ Telephone Nwnber: ran. can or gan) -------------------------------------------------------------------------------------------------------------------------------------------------------------------------- PART 11-TO BE COMPLETED BY RECOM)ER Date of InstrumentBook/I.D. Page/I.U.O 0 023 Dale or Recording City o 'f wnship � Play � OM4 Contract ❑ County DNR form(July 99) FILE WITH RECORDER 542-0960 (See instruction /IG) INSTRUCTIONS FOIL COMPLETING GROUNDWATER HAZARD STATEMENT - The transferor of real property is required to complete Part I of(his 3. Hazardous 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 (455B), I.A.C., and federal for filing instruments of conveyance of real property with the regulations referenced (herein. It is generally defined as waste county recorder(Iowa Code Section 558.69). The Department of that poses a threat to human health 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 property interest or that of Fedcral Regulations (40 CFR 261). EXCLUDED are 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 farnmer in accordance with the manufacturer's For the most part the information requested is clear (name, instructions, triple-rinsed agricultural chemical containers address, cic.). One statement under each of the numbered items disposed of by farmers (where the rinsate is used as makeup (I, 2, 3, 4 and 5) must be checked, and if one or more of the water in time tankmix and applied at appropriate rates), and other statements checked requires the transferor to provide additional specific materials. Persons arc legally required to be aware of information,that information is to be provided in part l: 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 '['auks - "Underground storage lank" 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 slatennenls at the end of Part piping connected to the links, used to contain all accumulation of 1 and attach the additional information to all copies of the form. regulated substances, and the volunmc 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 sliecific 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 form. a. Farm 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 augcred, washed, driven, dug, jetted or otherwise constructed for See 455B.473(4)) accessing groundwater or for diverting surface water into time b. Tanks used for storing inciting oil for consumptive use on time ground, including abandoned wells. "Well" dots not include an premises where stored. ial opera ditch or drainage tiles which discharge to line surface. c. c tariks. d. Pipeline lfacilities regulated by state or federal law. If a well is an"abandoned well"or an"agricultural drainage well," c. A surface impoundment,pit pond,or lagoon. (his must be identified and tine status of the well with respect to f. A stonn water or wastewater collection system. Iowa Code sections 45513.190 and 159.29, respectively, must be g. A (low-through process tank. stated. 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 lank in an underground area such as a basement or mine, if the tank is on or above the surface of the floor. chapter 39 of the rules of the Department of Natural Resources. (567 Iowa Administrative Code,Chapter 39) j. Pipes connected to the above exclusions. Aim "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 [FRP], or other [specify]), and any'internal or to an aquifer(underground), excluding drainage tile.intakcs 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 are to Identify the capacity in gallons and the substance stored in each develop a plan proposing alteratives to the use of the well by lank. July 1, 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 lransferor shall stale the location of the site. For each decedent include dirt,stone,brick,or similar inorganic material used for fill, buried on the property, the transferor sliall slate 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 Administra live Code (I.A.C.) for further definitions. A death,and date of birth. "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 (o the was regulated by the department. county recorder when the document to be recorded is filed. lime Recorder shall forward the original to the transferee when the If the transferor or agent has not received notice from the recorded instrument is returned. The recorder is not required to Department of Natural Itcsources that the disposal site has been keep any copies. _ -deenmed_lo—bc polentialiy_hazardousLilncre_is no duty to inquire to the department. *Note The land application of sludges or soils resulting from the remcdiation of underground storage tank releases accomplished in O compliance with Department of Natural Resources rules without a O permit is not required to be reported as the disposal of solid waste or hazardous waste. (See Iowa Code Section 558.69) 1 0 r_�: cl� C 543-0961 DNR form(July 99)