HomeMy WebLinkAboutA013 - 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 of Print Legibly)
TRANSFEROR Name Grand Junction, L.C.
Address 904 Walnut Street,Suite 900 Des Moines Iowa 50309-3574
Number and Street or RR City,Town or P.O. State Zip
TRANSFEREE Name Grand Junction, L.C.
Address 904 Walnut Street,Suite 900 Des Moines Iowa 50309-3574
Number and Street or RR City,Town or P.O. State Zip
--_,_Flatted
Address of Property 539 Lincoln Way Ames Iowa—L 50010
Number and Street or RR City,Town or P.O. State Zip
Legal Description of Property Grand Junction Subdivision,an Official plat now included in and forming a part of the City of Ames Story
County,Iowa,a revlat of Parcel"F"in the Southwest Quarter of the Southwest Quarter of Section 2 Township 83 North Ranee 24 West of
the Yh P.M.,Ames,Story County,Iowa(as recorded in Book 14,Page 30 Instrument#96-07861 Story Countv Recorder's Office on 7-30-96)
(Please note: No property is being transferred but this property is being platted)
1. Wells(check one)
® 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)
❑ 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)
® 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 substances(s)contained are
described below.
5. Private Burial Site(check one)
® There are no known private burial sites on this property.
❑ There is a private burial site on this property. The location(s)of the site(s)is stated below. The known identifying information of the
decedent is stated below.
Information,if any,required by statements check above: There is hydrocarbon contamination on a portion of this site from former
underground storage tanks that had been located on the portion previously known as Parcel"C"in the SW'/4 of the SW'/4 of Section 2-83-24,
in the City of Ames, Story County,Iowa. The former owner of said Parcel"C",Doolittle Oil Company,Inc.has signed an Environmental
Indemnity Agreement with Hubbell Realty Company and Grand Junction,L. C. and is responsible for managing this situation in accordance
with Iowa Department of Natural Resources rules.
Attachment for Additional Information? Y/(lj➢ If so,number of pages
I HEREBY DECLARE THAT THE INFORMATION CONTAINED IN PART I OF THIS STATEMENT IS TRUE AND CORRECT.
Grand Junction, L.C. By: Hubbell Realty Company, Manager
Signature: By: .�.<lf/' Telephone Number: (515)280-2051
(Transferor or Agent) FdMichael Hayes, Secretary
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PART H-TO BE COMPLETED BY RECORDER �9
Date of Instrument �y
a� ��"�9 Book/I.D. Page/I.D. � 8 9 �
Date of Recording 9 C( ity dr Township A yrQz
PI SA,
Deed ❑ Contract ❑ County
--------------------------V-------------------------------------------------------------------------------------------DNR form(July 99) FILE WITH RECORDER 542-0960
(See Instruction#6)
895
INSTRUCTIONS FOR COMPLETING GROUNDWATER HAZARD STATEMENT
The transferor of real property is required to complete Part I of this 3. Hazardous Wastes - "Hazardous waste" is defined in Iowa
form. The purpose of the statement is to satisfy legal requirements Code section 455B.411, 567--141.2 (455B), I.A.C., and federal
for filing instruments 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 health or the environment. It
Natural Resources does not approve or disapprove of property includes wastes which are 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 Federal 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 conditions, 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, etc.). One statement under each of the numbered items disposed of by farmers (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 tankniix and applied at appropriate rates), and other
statements checked requires the transferor to provide additional specific materials. Persons are legally required to be aware of
infonnarion thatinformatiQn is to_be proyided in Part I. Relate the hazardous_wa_ste 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 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 the 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 comer of the property. A identified in 567--135.2(455B), I.A.C. Underground storage
professional survey is not necessary. The following defmitions 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
augured, 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 the 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 455B.190 and 159.29, respectively, must be g. A flow-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 disreair that continued se is unsafe o
ur-impracticable. oil or g sa production and
p gathering operations. -
Abandoned wells are to be properly plugged in accordance with i. A tank in an underground area such as a basement 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 [FRP], or other [specify]), and any internal or
to an aquifer(underground), excluding drainage file intakes which external protection such as a protective coating or wrapping, or
outlet to the surface. Agricultural drainage wells are 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 alternatives to the use of the well by tank.
July 1, 1998. (See 1991 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 transferor 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 transferor shall state all known
as long as no other solid waste is included. See 567-100.2(455B), identifying information of that decedent including name, date of
Iowa Administrative Code (I.A.C.) for further defmitions. 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 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 transferor 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 copies.
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 Iowa Code Section 558.69)
DNR form(July 99) 543-0960
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