HomeMy WebLinkAboutA010 - Real Estate Transfer - Groundwater Hazard Statement REAL ESTATE TT2ANSFM - GROUNDWATER HAZARD STATEMENT
Please read the filing instructions on 'the reverse aide BEFORE completing this form.
PART I - TO BE COMPLETED BY TRANSFEROR
(Pteabe Tvm 0A P t i.nt L egibtV)
TRANSFEROR Name RON COY Social Security No.
(or Federal I.D. No. ) 480-66-9706
Address 2720 Luther Drive Ames IA 50010
Number and Street or RR City, Town or P.O. State
'zip
TRANSFEREE Name DEARBORN ESTATES, AMES, IOWA Social Security No.
Address (or Federal I.D. No. )
Number and Street or RR City, Town or P.O.
State Zip
Address of Property .Transferred
Number and Street City, Town or P.O. State_- -- --- Zi p
Legul Description of Property
1. Wells. (check one)
fX) ,There are no known wells situated on this property. ,.
E] There is a well or wells situated on this property. The type(s), location(s), and
legal status are stnted'below.
2. Solid Waste Disposal. Cch.eck one)
W There is no known solid waste disposal site on this property.
El There is a soiid 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.
13 There is a solid waste disposal site on this property which has been deemed to be
Potentially hazardous by the department of natural resources
sit . The location(s) of the
es) is stated below.
3. Hazardous Wastes. (check one)
5d- Thore is no known hnzardous waste on this property.
C) 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)
Fg] There are no underground storage tnnks on this property. (Note exclusions such as
small farm and residential motor fuel tanks, most heating oil tanks, cisterns, and
septic tanks, in instructions. )
I] There is an underground storage tank or tanks on this property. The type(s), size(s),
and substance(s) contained are described below.
Information, if any,_ required by statements checked abovei
Attachment for Additional-Information? YIN If so, number of pages T
I 'HEREBY DECLARE THAT. THE INFORMATION CONTAINED IN PART .I OF THIS STATEMENT IS TRUE AND
ND
Signatures �.
Telephone Numbers (515
( nnsferor)
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PART II - TO BE CO ------------------------
I COMPLETED BY RECORDER
Date -of Instrument 711I q/
IIook/I .D. Page/I.D. /
Date .of Recording f7 1q1
ity o Township
'. Deed .. •�s� Cl'i�l. �. •
Contract''a. County
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