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Home My WebLink AboutA012 - 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) 10 rr 11 P Social Security No. �a, t 30�(,�-�•�( ANSFEROR Name -�dt'"A- "�� Vl��l,trs� t`e 5e,&'r'� (or Federal I.D. No.) Address 4�S61 Was-YA hood pr-WeI5u-.1t Gop Ttme5- (0 Number and Street or RR City,Town or P.O. State Zip Social Security No. ANSFEREE Name /A (or Federal I.D. No.) Address Number and Street or RR City,Town or P.O. State Zip Jress of Property Transfered Q d&�,tt5-.Tay Ski &IA �7' "i Number and Street or RR City,Town or P.O. State Zip jal Description of Property 1s1 o-^ 5 (�► `t^ d„live. , 1 "e Sea �c�l P61� �< �1i�� ai�d-to-✓�) AA 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 properly, 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. Yardous 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: Attachment for Additional Information? Y / N If so, number of pages I HEREBY DECLARE THAT THE INFOR ATION CONTAINED IN PART I OF THIS STATEMENT IS TRUE AND CORRECT. � Signature: K('_ � Telephone Number: �� 3a ` �6 (Transfero or Agent) ------------------------------------------------------------------------------------------ .� Iq?- 0�613 Date of Instrument I � I q�PART II -TO BE COMPLETED BY RECORDER-_ Book/I.D. Page/I.D. Date of Recor ng 3 jjq19q C)Ownship awls - Deed ly M Contract ❑ County ------------------------------------------------------------------------------------------- DNR form (SEPT. 93) FILE WITH RECORDER 542-0960 (See Instructions, 115) 'INSTRUCTIONS FOR COMPLETING GROUNDWATER HAZARD STATEMENT The transferor of real property is required to complete 3. Hazardous Wastes - "Hazardous waste", is defined it Part I of this form. The purpose of the statement is to Iowa Code section 4556.411, 567-141.2 (455B), I.A.C. satisfy legal requirements for filing instruments of and federal regulations referenced therein. It is generall,, conveyance of real property with the county recorder(Iowa defined as waste that poses a threat to human health o 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 specificall, transfers based on these statements. The statement must listed as hazardous in the Code of Federal Regulation 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 sot represents the information from transferor to be correct. conditioners, agricultural chemicals applied or dispose( of by a farmer in accordance with the manufacturer'; For the most part the information requested is clear(name, instructions,triple-rinsed agricultural chemical container, address, SSN, etc.). One statement under each of the disposed of by farmers .(where the rinsate is used a, numbered items (1, 2, 3 and 4) must be checked, and if makeup water in the tankmix and applied at appropriat( one or more of the statements checked requires the rates), and other specific materials. Persons are legalli, transferor to provide additional information, that informa- required to be aware of hazardous waste laws. tion is to be provided in part 1. 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 combination of tanks, includin( 4). If additional space is needed, type or print it legibly underground piping connected to the tanks, used t( on a separate sheet or sheets, complete the statements contain an accumulation 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 surfac( to all copies of the form. When describing the location of the ground. "Regulated substances" include petroleun of a facility on the property, be reasonably precise, such products and hazardous or toxic materials identified it as a specific distance .and general direction from a 567-135.2(455B), I.A.C. Underground storage tank doe; 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 les completing the form. capacity used for storing motor fuel for noncommer 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, augered, washed, driven, dug, jetted or otherwise use on the premises where stored. constructed for accessing groundwater or for diverting c. Residential septic tanks. surface water into the ground, including abandoned wells. d. Pipeline facilities regulated by state 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, related to oil or gas production and gatherinc with respect to Iowa Code sections 455B.190 and 159.29, operations. respectively, must be stated. An "abandoned well" is a i. A tank in an underground area such as a basemen well no longer in use or in such state of disrepair that or mine, if the tank is on or above the surface o continued use is unsafe or impracticable.Abandoned wells the floor. are to be properly plugged in accordance with chapter j, Pipes connected to the above exclusions. 39 of the rules of the Department of Natural Resources. (567 Iowa Administrative Code, Chapter 39) "Tank type" means the material of construction (steel fiberglass reinforced plastic[FRP],or other[specify]),an( An "agricultural drainage well" is a well constructed for any internal or external protection such as a protectiv( the purpose of draining, or which d(ains, water from agricultural land to an aquifer (underground), excluding coating or wrapping, or cathodic protection. drainage the intakes which outlet to the surface. Identify the capacity in gallons and the substance store( Agricultural drainage wells'are rectoired 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 presente( a plan proposing alternatives to the use of the well by to the county recorder when the document to be recorde( July 1, 1994 (See Iowa Code Section 159.29.) is filed. If any of the four questions are answered in th( affirmative so that explanations are required, a duplicat( 2. Solid Waste - "Solid waste" means garbage, refuse, copy (or photocopy) of this form must be filed with th( rubbish and other similar discarded solid or sernisolid recorder. In cases where all four questions are answere( material. I1 does not include dirt, stone, brick, or similar in the negative, this form will be forwarded by the recorde 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 affirmativ( trative Code (I.A.C.) for further definitions. A "disposal so as to require an explanation, the recorder shall furnist site" is any area on the property on, in, or under which the original of this form to the transferee and forward th( solid waste has been disposed,whether or not the disposal photocopy or other duplicate copy suitable for microfilm. is or was regulated by the department. ing to the department.The recorder is not required to keen If the transferor or agent has not received notice from any copies. the Department of Natural Resources that the disposal site has been 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) f� a �Y/t Printed on Recycled Paper CPF-86861 542-0960