HomeMy WebLinkAboutA005 - Grounwater 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)
Hunziker Development Co. , L.C. Social Security No.
TRANSFEROR Name p (or Federal I.D. No.) 42-1394281
Address 105 S. 16th Street Ames IA 50010
Number and Street or RR City,Town or P.O. State Zip
TRANSFEREE Name Second Addition, Hillside Subdivision, in Social Security No.
Ames, Io a (or Federal I.D. No.)
Address CL� 6 " Ict.c_n Siit• �MV,4>_ ,�Oojo
Number and Street or FM U City,Town or P.O. State Zip
Address of Property Transfered
Number and Street or RR City,Town or P.O. State Zip
Legal Description of Property Hillside Subdivision, Second Addition, being an official re-plat
of Outlot "Z" in Hillside Subdivision First Addition, an Official Plat, Ames, Story
County, Iowa.
1. Wells (check one)
K 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)
R 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;
X 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
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 DECLARE THAT THE INFORMATION CONTAINED IN PART I OF THIS STATEMENT IS TRUE
AND CORRECT.
Sigrtature: Cl�nSyl,nQ_ A . kAA ,l (Ck✓ 5
Chri I.II
stine �nziker (Transferor or Agent) Attorney Telephone Number:
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PART II - TO BE COMPLETED BY RECORDER
Date of Instrument —��- ��P Book/I.D.E Page/I.D. 15��
-Date of Recording �%3b _ (o C or Township m
Deed 2� 7"
Contract ❑ County
L
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DNR form (JAN. 91) FILE WITH RECORDER
642-0960
(See Instructions, #5)