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HomeMy WebLinkAboutA010 - Real Estate Transfer - Groundwater Hazard Statement f.> h O 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 �� / � ,.,^ n�a�seTye or Pr v�j,'� 1,� � I� /� Social Security No. TRANSFEROR Name �� LA �'�`"' �7?&Q' <"(or Federal I.D. No.) Address �Q3 —j Number and Street or RR City,Town or P.O. State Zip Social Security No. AV TRANSFEREE Name «� (or Federal I.D. No.) Address Number and Street or RR ty,Town or P.O. State Zip Address of Property Transfered �������� Number nnand Street or RR City,Town oorj P.O..y State Zip Legal Description of Property 1. Welp(check one) here are no known wells situated on this property. o 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) B,'fhere 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. Un ground Storage Tanks (check one) ET 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 �e ff-- �2�Signature: %� �' Telephone Number: ( ) (Transferor or Agent) ------------------------------------------------------------------------------------------ PART II - TO BE COMPLETED BY RECORDER Date of Instrument �I a�J II Book/I.D. Page/I.D. Date of Recording �aJ°�/ City o Township s Deed ❑ Contract ❑ County ------------- ---------------------------------------------------- DNR form (JUL 89) FILE WITH RECORDER 542-0e60 (See Instructions, #5) INSTRUCTIONS FOR COMPLETING GROUNDWATER HAZARD STATEMENT The transferor of real property is required to complete 3. Hazardous Wastes - "Hazardous waste" is defined in Part I of this form. The purpose of the statement is to Iowa Code section 455B.411, 567-141.2 (455B), I.A.C., satisfy legal requirements for filing instruments of and federal regulations referenced therein. It is generally conveyance of real property with the county recorder(1989 defined as waste that poses a threat to human health or Iowa 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 specifically transfers based on these statements. The statement must listed as hazardous in the Code of Federal Regulations 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 soil represents the information from transferor to be correct. conditioners, 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, SSN, etc.). One statement under each of the disposed of by farmers (where the rinsate is used as numbered items (1, 2, 3 and 4) must be checked, and if makeup water in the tankmix and applied at appropriate one or more of the statements checked requires the rates), and other specific materials. 'Perso'ns are legally transferor to'provide additional information, that informa- required to be aware of hazardous waste laws._ -tion is to-be provided-in Part I. 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, including 4). If additional .space is needed, type or print it legibly underground piping connected to the tanks, used to 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 surface to all copies of the form. When describing the location of the ground. "Regulated substances" include petroleum of a facility on the property, be reasonably precise, such products and hazardous or toxic materials identified in as a. specific distance and general direction from a 567-135.2(455B), I.A.C. Underground storage tank does 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 less completing the form. capacity used for storing motor fuel for noncom- mercial 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. f. A storm water or wastewater collection system. If a well is an"abandoned well"or an"agricultural drainage 9• 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 with respect to Iowa Code sections 455B.190 (as amended related to oil or gas production and gathering by 1989 Iowa Acts; Senate File 441) and 159.29, respec- operations. tively, must be stated. An~'abandoned well"-is-a Well'no i.--A-tank-in an-underground area-such as a basement longer in use or in such state of disrepair that continued or mine, if the tank is on or above the surface of use is unsafe or impracticable. Abandoned wells are to the floor. be properly plugged in accordance with chapter 39 of the j• Pipes connected to the above exclusions. rules of the.Department of Natural Resources. (567 Iowa "Tank type" means the material of construction (steel, Administrative Code, Chapter 39) fiberglass reinforced plastic[FRP],or other[specify]),and An "agricultural drainage well" is a well constructed for any internal or external protection such as a protective the purpose of draining, or which drains, water from coating or wrapping, or cathodic protection. agricultural land to an aquifer(underground), 'excluding Identify the capacity in gallons and the substance stored drainage tile intakes which outlet to -the,surface. in each tank. Agricultural drainage wells are.required to be registered with the department by September 30, 1988,and the owner 5. Filing - The original of this form must be presented of the well and of the land drained by the well are to develop to the county recorder when the document to be recorded a plan proposing alternatives to the use of the well by is filed. If any of the four questions are answered in the July 1, 1991. (See 1989 Iowa Code Section 159.29.) affirmative so that explanations are required, a duplicate copy (or photocopy) of this form must be filed with the rubbish and other similar discarded solid or semisolid 2. Solid Waste - "Solid waste" means garbage, refuse, recorder. In cases where all four questions are answered in the negative,this form will be forwarded by the recorder material. It does not include dirt, stone, brick, or similar to the transferee when the recorded instrument is returned. inorganic material used for fill, as long as no other solid If.any of the questions are answered in the affirmative waste is included. See 567-100.2(4556), Iowa Adminis- so as to require an explanation, the recorder shall furnish trative Code (I.A.C.) for further definitions. A "disposal the original of this form to the transferee and forward the site" is any area on the property on, in, or under which photocopy or other duplicate copy suitable for microfilm- solid_i[-asteJlas-beendi.sp-osad,-WtLbther_or_no-tthe_disp.osal in to"the de artment The recorder is-not re cared to Kee is or was regulated by the department. g p q F-- any copies. If the transferor or agent has not received notice from the Department of Natural Resources that the disposal site h-as been deemed to be potentially hazardous, there-is no duty to inquire to the department. CPF-86861 542-0960 EXHIBIT "A" Part of Lot 9 in Landmark Subdivision to Ames, Story County, Iowa, situated in the Northeast Quarter of Section 7, Township 83 North, Range 24 West of the 5th P.M. , and more particularly described as follows: Commencing at the Northeast corner of said Section 7; thence S8903814411W, 49 . 00 feet along the North line of the Northeast Quarter of said Section 7; thence S000010011W, 249. 12 feet, parallel with the East line of the Northeast Quarter of said Section 7 to a point on the Easterly line of said Lot 9 and the point of beginning; thence, N07°44 ' 58"W, 7 .4�2 feet along said Easterly line of Lot 9; ,thence Northwesterly, 327.00 feet along the Northerly line of Lot 9, along a curve having a radius of 1392.50 feet, concave Southwesterly through a central angle of 13027117" , and having a chord which bears N6603210111W; thence N88034122" W, 4 .73 feet along the Northerly line of said Lot 9; thence S00°001001-W, 198. 14 feet; thence N89038144"E, 305. 00 feet to a point that is 4 . 00 feet West of the East line of said Lot 9; thence N0000010011E, 58. 88 feet to the point of beginning, containing 0.98 acres. Said real estate is also described as Parcel "B" as shown on the Plat of Survey filed for record on the 27th day of February, 1991, in Certificate and Field Notes Book 9, Page 248 in the office of the Story County, Iowa Recorder.