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HomeMy WebLinkAboutA010 - Real Estate Transfer - Groundwater Hazard Statement Ri:AL ESTATE 'TRANSFER - GROUNDWATER HAZARD STATEMENT ,• Please read the filing instructions on the reverse side BEFORE completing this form. PART 1 - TO BE COMPLETED BY 'TRANSFEROR (]'lease 'Type or Print Legibly) TRANSFEROR Name Erben Hunziker Trust et al. Address 105 S. 16th'FlStreet_ Ames _ _ Iowa 50010 um er an beet or F — lily, n'r u•n or 1. �tatc zip TRANSFEREE Name 8th Addition, Somerset Subdivision Address um cr an trcel or - z`ny,'lown or state Zip —Address-of Property-Transferred— um cr and,beet nr tR ---'iZ ity, own,or P.O. S late —Zip Legal Description of Property Lot 2 of Block 2 in Somerset Subdivision 5th Addition, an Official Plat, City of Ames, Story County, Iowa L Wells(check one) There are no known wells situated on this property. ❑ There is a well or wells situated oil 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. Cl There is a solid waste disposal site on this property,but no notice has been received from (lie Department of Natural Resources that the site is deemed to be potentially hazardous. L7 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) Jld,'There-is no known hazardous waste on this property. _ ❑ There is hazardous waste oii this property and it is being managed in accordance with Department of Natural Resources rules. 4. Underground Storage Tanks (check one) } O�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) X'1ltere are no known private burial sites on this property. ❑ There is a private burial site on this properly. 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 I HEREBY DECLARE CONTAINED IN PART I OF'1'IIIS STATEMENT IS TRUE AND CORRECT Signature: r` 'Telephone Number: (515 33-VL 50 1 Tails cim ur ARcnll — --— PART 11 -To BE C0 MI,I,E'rED BY RECORDER ®© Date of Instrument �D 1300 e ®3 9 9— — ---- ------ Page/I.D. Date R ruing— -------- City or' ownship C Deed' Contract H Count - -- ------- ------- -------'----------- - DNR form(July 99) Fl1,G WITII RECORDER 542-0960 (Sec Instruction //6) , INSTRUCTiONS FOR COMPLETING GROUNDWATER HAZARD STATEMENT 'File transferor of real property is required to complete part I of this 3. Hazardous Wastes - "Hazardous waste" is defined in Iowa form. 'I'lle purpose of the statement is to satisfy legal requirements COdc section 45513.411, 567--141.2 (455I3), I.A.C., and federal for filing nlstrulltents of conveyance of real property will' the regulations referenced therein. It is generally defined as waste county recorder (Io%va Code Section 558.69). The Department of that poses a threat to human health or the environment. It Natural Resources does not approve or disapprove of property includes wastes which are ignitable, corrosive, toxic, explosive, transfers based on these statements. The statement "'list be signed violently reactive, or specifically listed as hazardous in the Code by one of file persons transferring the property interest or that of' Federal Regulations (40 CFR 261). EXCLUDLD are person's agent. An agent signing this form represents the household wastes, agricultural wastes returned to the soil as Information front transferor to be correct. fertilizers or soil 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, etc.). One statement under each of the numbered items disposed of by farmers (where the rinsate is used as makeup (l, 2, 3, 4 and 5) must be checked, and if one or more of file water in the tankmix and applied at appropriate rates), and other statements checked requires the transferor to provide additional specific materials. Persons are legally required to be aware of information, that information is to be provided in part 1. Relate the hazardous waste laws. additional information to the specific category of facility (well, etc.) by nunlber-ing it with the corresponding number (1, 2, 3, 4, 4. Underground Storage.Tanks _ "Underground storage (allb:" 5). 11' additional space is needed, type or print it legibly on a means one or a combination of tanks, including underground separate sheet or sheets, complete the statements at the end of fart piping connected to the tanks, used to contain an accumulation of i and attach (lie additional information to all copies of the form. regulated substances, and the volume of which is 10 percent or When describing the location of a facility on the property, be more beneath the surface of the ground. "Regulated substances" reasonably precise, such as a specific distance and general include petroleum products and hazardous or toxic materials direction from a landmark or corner of the property. A identified in 567--135.2(455B), I.A.C. Underground storage professional survey is not necessary. The following definitions are tank does not include: for use in completing the lin-m. a. I-arnl or residential tanks of 1,100 gallons or less capacity L Wells - A "well" is any excavation that is drilled, cored, bored, used for storing motor fuel for noncommercial purposes. But angered, washed, driven, dug, jetted or otherwise constructed for See 455B.473(4)) accessing groundwater or for diverting surface water into the b. Tanks used for storing lleating oil for consumptive use on the ground, including abandoned wells. "Well" does not include an premises where stored. open ditch or drainage tiles which discharge to the surface. c. Residential septic tanks. d. Pipeline Facilities regulated by state or federal law. if a well is an"abandoned well"or an"agricultural drainage well," e. A surface impoundment,pit pond, or lagoon. this must be identified and the status of the well with respect to f. A storm water or wastewater collection system. lows Code sections 45513.190 and 159.29, respectively, must be g. A flow-through process tank. stated. An:'abandoned well" is,a ;vsll no longer in use or in such It. A liquid trap or associated gathering lines directly related to state of disrepair that contin'led use is unsafe or impracticable. oil or gas production and gatheriiib operations. _ Abandoned wells are to he prop__ -1�luggedisi '��nr_cli�nc.e.�uiflt _.._tank in-an-uladergrou+ld-area-stack-as-a-basement-or-rlrrlte iif--= chapter 39 of the rules of the Department of Natural Resources. the tank is on or above the surface of the floor. (567 Iowa Administrative Cod'c.,Cl1ap'.er,39) j. Pipes connected to the above exclusions. An ':agricultural drainage well" is a well constructed for the `"yank type" means the material of construction (steel, fiberglass purpose of draining, or which drains, water from agricultural land reinforced plastic [FRP], or other [specify]), and any internal or to an aquifer(underground), excluding drainage tile intakes which external,protection such as a protective coating or wrapping, or outlet to the surface. Agricultural drainage wells are required to cathodic protection. be registered with the department by September 30, 1988, and the owner of the well and of the land drained by the well are to identify the capacity in gallons and the substance stored in each develop a plan proposing alternatives to the use of the well by tank. July I, 1998 (See Iowa Code Section 159.29.) 5. Private Burial Sites - "Private Burial Site" means one or 2. Solid Waste - "Solid waste" means garbage, refuse, rubbish more graves containing human remains. For cacti site the and other similar discarded solid or semisolid material. it(foes not transferor shall slate the location of the site. For each decedent include dirt,stone,brick, or similar inorganic material used for fill, buried on the property the transferor shall state all known as long as no other solid waste is included. See 567--100.2(455B), identifying information of that decedent including name, date of Iowa Administrative Code (I.A.C.) for further definitions. A death, and dale of birth. "disposal site" is any area on the property on, in, or nuclei- which solid waste has been disposed, whether or not the disposal is or 6. Filing - The original of this Form must be presented to the was regulated by the department. county recorder when the document to be recorded is filed. 'File _Recorder_shalLLorwalxi_the-origillarl- to the trans,'i�ree=evhen-ih::--` —=Ff—lire Crausfeior or i'gei't liasiiot receive' notice from the recorded instrument is returned. The recorder is not required to Department of Natural Resources that the disposal site has been keep any copies` deemed to be potentially hazardous, there is no duty to inquire to the department. *Note The land application of sludges or soils resulting front the rentediation of underground storage tank releases accomplished in compliance with Department of Natural Resources rules without a O permit is not required to be reported as the disposal of solid waste or hazardous waste. (See Iowa Code Section 558.69) O W co co DNR form(July 99) 543-0960 f