HomeMy WebLinkAboutA009 - 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 <Srh a-4z� to (or Federal I.D. No.)
Address LC-5- :5 I&Ye7 ALP7. �� -50 /
Number and Street or RR City,Town or P.O. State Zip
/�Dr-i+hr;�� �L //L`jl or Fe Security No.
TRANSFEREE Name _ T (or Federal I.D. No.)
Address
Number and Street or RR City,Town or P.O. State Zip
Address of Property Transfered 4--
Number and Street or RR City,Town or P.O. State Zip
Legal Description of Property
1. Wells check one)
here 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)
�T re 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)
mere 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. r
4. Underground Storage Tanks (check one)
A-T#exe 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 DECLA AT THE INFORMATIO CONTAINED IN PART I OF THIS STATEMENT IS TRUE
AND CORREC .
Signature: Telephone Number: 675 ��2'-� Z
(T nsferor or Agent)
---------------------------
PART II - TO BE COMPLETED BY RECORDER Fj 05208�- _
Date of Instrument J 311k Book/I.D. q Page/I.D.
Date of Rec�ordy'Rg ✓ 3/ City or T nship
Deed E!< P14thtj)
Contract ❑ County
DNR form (SEPT. 94) FILE WITH RECORDER 54e-0960
(See Instructions, #5)