HomeMy WebLinkAboutA017 - Real Estate Transfer - 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 ��� LGG;-, 5�-er �i'rx (or Federal I.D. No
1/ . `�
Address PS'\ �} 1-�.�- 13-
Number and Street or RR11 City,Town or .O. Social Security No. State Zip
TRANSFEREE Name (or Federal I.D. No.)
Address V.)� l e_�� e ,; l ck � l"
Number and Street or RR Cit ,Town o P.O. State Zi
Address of Property Transfered DSO
Number and Street or RR City,Town o P.O. State Zip
Legal Description of Property "1{�
�1 1 V C.it�'• ��.t`7 C .. � ���.i U'�J.rl
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. S lid 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)
here 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. )nderground Storage Tanks (check one)
There are no 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.) _.
o There is an underground storage tank or tanks on this property. The type(s), size(s) and 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
(-HEREBY DECLARE-THAT THE-INFORMATION-CONTAINED IN PART VOF THIS STATEMENT—IS TRUE-AND
CORRECT. 1 (�
Signature: Telephone Number: )
(Transferor or Age_t)
PART II - TO BE COMPLETED BY RECORDER
Date of Instrument �� Book/I.D. ® Page/I.D. �z
Date of Recording �( I9 Z— City
Deed ❑ �l a� _; �� �
Contract ❑ County
DNR form (Nov 87) FILE 3 COPIES WITH RECORDER 542-0960