HomeMy WebLinkAboutA015 - Groundwater Hazard Statement REAL ESTATE TRANSFER - GROUNDWATER HAZARD STATEMENT
Please read the filing instructions on the reverse side BF,FORF, completing this form.
PART I - TO BE COMPLETED BY TRANSFEROR
(Please Type or Print Legibly)
TRANSFEROR Name Erben Hunziker Trust, et al.
Address 105 S. 16th Street Ames Iowa 50010
Number and Street or RR city.'rown or P.O. sfa—te- .tp
TRANSFEREE Name 7th Addition, Somerset Subdivision
Address
Number and Street or RR City,Town or P.O. State zip
Address of Property Transferred
Number and Street or RR City,Town,or P.O. State Zip
Legal Description of Property An official replat of 0utlot M in Somerset Subdivision Third Addition,
an official replat;-all now included in and forming a part of the City of Ames, Story
County, Iowa.
1. Wells(check one)
Dl'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)
id—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) •
K 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)
J There are no known underground storag-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.
5. Private Burial Site(check one)
°here are no known private burial sites on this property.
❑ There is a private burial site on this property. The location(s)of the site(s)is stated below. The known identifying information of the
decedent is stated below.
Information, if any,required by statements checked above:
Attachment for Additional Information? Y/N If so,number of pages
I HEREBY DECLA T THE INFORMATION CONTAINED IN PART 1 OF THIS STATEMENT IS TRUE AND CORRECT
Signature: Telephone Number: _(_)
( ra eror or gent) IV
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PART II-TO BE COMPLETED BY RECORDER '9 1 5 4 1 O
Date of Instrument I 1 (q'9 UQ"W-f3- I.D.
Date of Recording " ` -- 1 Cit or Township o, tA, 1
Deed [- Contract ❑ County
DNR form(July 99) FILE WITH RECORDER ------------------
----------------- ---------Paz-o96o
(See Instruction#6)