HomeMy WebLinkAboutA016 - 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 Erben Hunziker Trust , et al . (or Federal I.D. No.)
Address 105 S. 16th St. Ames Iowa 50010
Number and Street or RR City,Town or P.O. State Zip
Social Security No.
TRANSFEREE Name 4th Addition, Somerset Subdivision (or Federal I.D. No.)
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 An Official Replat of Outlot Z in Somerset Subdivision
First Addition, an Official Plat, and Outlot C in Somerset Subdivision
Second Addition, an Official Plat , all now included in and forming a part
of the City ot Ames , Story County, Iowa
1. Wells (check one)
X 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)
XThere 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? XX N If so, number of pages
I HEREBY DECLARE THAT THE INFORMATION CONTAINED IN PART I OF THIS STATEMENT IS TRUE
AND CORRECT. ( -
Signature: ez� �'�'S�-ter (� rtz&a'-`�Wp one Number: (51 r) Z3 Z- U, ?.-
(Transfer or Agent)
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PART II - TO BE COMPLETED BY RECORDER (� ` O
Date of Instrument I I Book/I.D. Page/I.D. t7 7 "
Date of Reco ding U ' City or ownship ft
Deed
n Cor tact ❑ County
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DNR,foxm (SEPT. 97) FILE WITH RECORDER 542-0960
(See Instructions, #5)