HomeMy WebLinkAboutA010 - 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.
TRANSFEROR Name HORNE-AMES, LLC (or Federal I.D. No.) 62-1688492
�y t 205
++' Address xecutive Tower Drive Knoxville, Tennessee 37923
Number and Street or RR City, Town or P.O. State Zip
? Social Security No.
TRANSFEREE Name NA
(or Federal I.D. No.)
Address
a 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
Legal Description of Property Parcel "E" SW 1/4 ® 14-T83N - RZ4W
Plat of survey filed 5-27-97 #97-05150 to be known as Horne Subdivision, Ames, Iowa.
1. Wells (check one)
i ❑ 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.*
t
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 substance(s)
contained are described below.
Information, if any, required by statements checked above:
*Three (3) ground water monitoring wells were installed and utilized on the Property
in March, 1997 to obtain ground water samples, which revealed no concentration above
applicable standards. The ground water monitoring wells are not active and are capped
with locking steel covers.
i
I
Attachment for Additional Information? Y / J If so, number of pages
I HEREBY DECLARE THAT THE INFORMATION CONTAINED IN PART I OF THIS STATEMENT IS TRUE
AND CORRECT
Signature: Telephone Number: (4
i (Transferor or Agent)
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PART II - TO BE COMPLETED BY RECORDER
p., 0 136'70
Date of Instrument_�Z,-��1-� l Book/I.D. ln" Page/I.D.
Date of Recording : ( - City Township
Deed K c' -
Contract ❑ County � rU
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DNR form (SEPT. 96) FILE WITH RECORDER saz-osso
(,';Pp. Instnintinns 45)