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Home My WebLink AboutA010 - Real Estate Transfer - Groundwater Hazard Statement 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. 'RANSFEROR Name f� W ��1�k - (or Federal I.D. No.) Address 207---5�kw Number and Street or RR City,Town or P.O. State Zip � Social Security No. 'RANSFEREE Name _ �� ; o� dH �,c9,f-49T S`'`�°� Sgbr Federal I.D. No,) Address Number and Street or RR City,Town or P.O. State Zip address of Property Transfered _— Number and Street or RR City,Town or P.O. State Zip egal Destriptioi: of Property .___ �i��e (_. _i^-- -. - 2 1. Wells (check one) 7� 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) & 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) I� 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.) ❑ 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 Information? Y / N If so, number of pages ' • , I HEREBY Dr AR INFORMATION CONTAINED IN PART*I-OF-THIS STATEMENT IS TRUE AND COR ECT. _ Signature. ` _ —�_ Telephone Number: (/rnsferor or Agent) ---------------------------------------------------- PART II - TO BE COMPLETED BY RECORDER 1.1159 to ll�_I_g7 q r Date of Instrument_._ ____ . ___ __ Book/I.D. Page/I,D. Date of Recording `O ``� City or wnship AWS Deed ❑ /I Contract El PI/ County r - ------ - ------------------------------------------- --------------------- DNR form (SEPT. 96) FILE WITH RECORDER 542-0960 (SPP Instnirtinns. #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, 567-1,11.2 (455B), I.A.C., satisfy legal requirements for filing instrUrnents of and federal regulations reforoiu:cd tllereln. It is generally conveyance of real property with the county recorder(Iowa defined as waste that poses a Ihreal lu human heallh 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,or specifically 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 For the most part the information requested is clear(name, iristructions,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 providedJih-part I 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 coinbiiiation of tanks,'including 4). If,additional space is needed, type or print it legibly underground piping connected to the tanks, used to on a separafe'sheet or sheets, complete the statements contain an accumu!ation 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 seirfr ce to all,eopies'of the form. When describing the location of the ground. "Regulated substances" include•petroleelm 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 a 567-135.2(455B), I.A.C. 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 luel for noncorrimer- cial 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, angered, washed, driven, dug, jetted or otherwise use on the premises whoro storec.l, constructed for accessing groundwater or for diverting c. Residential septic talks, surface water into the ground, including abandoned wells. d. Pipeline facilities regulated by stale 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. I. 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 45513.190 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 i 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 Natural Resources, 1• 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 tile intakes which outlet 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 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) rubbish and other similar discarded solid or semisolid p pY) of this form must be filed with the 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 :;hall 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 lot 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 The Recorder shall always forward the original to the has been deemed to be potentially hazardous, there is no transferee when the recorded inslreiirient is returned. duty to inquire to the department. 'Note The land,application of sludges or soils resulting from the renlediation of.underground storage tank releases accomp4ished.irl 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 Iowa Code Section 558.69) 1 ' 1 ii7 '1 i Recycled 1loper CPF-86861 542.0960