HomeMy WebLinkAboutA011 - 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
(Pjoncn T,,-- — o.;nt Legibly)
ERBEN A. HUNZER, TRUSTEE OF THE ERBEN A HUNZIKER Social Security No.
TRANSFEROR Name REVOCABLE TRUST, DATED JULY 29, 1992; DONALD (or Federal I.D. No.)
M. FURMAN AND RUTH W. FURMAN, CO—TRUSTEES OF THE DONALD AND RUTH FURMAN REVOCABLE
Address TRUST DATE MARCH 1, 1991; R. FRIEDRICH & SONS, INC, AMES COMMUNITY SCHOOL
DI n eRB T W. TAYLOji1Xt&`1E'MtiRY TAYLOR, HUSBAND AN liolFE. Zip
Social Security No.
TRANSFEREE Name SOMERSET SUBDIVISION FIRST ADDITION AMES (or Federal I.D. No.)
STORY COUNTY, IOWA
Address
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
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 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:
Attachment for Additional Information? X7( / N If so, number of pages
I HEREBY DECLA HAT THE INFO�r ATION CON AINED IN PART I OF THIS STATEMENT IS TRUE
AND CORRECT
Signature: Telephone Number: ( )
(Transferor or Agent)
PART II - TO BE COMPLETED BY RECORDER
Date of Instrument 1b Book/I.D. "1 f Page/I.D�
Date of Recording I City o Township
Deed ❑ n)
Contract ❑ r (,(' County �l V
DNR form (JAN. 91) FILE WITH RECORDER 54e-0960
(See Instructions, #5)