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Home My WebLink AboutA018 - 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) TRANSFEROR Natn�S L L.C. Address �'Lk r J� W (-1,11 C Q aRV& 1 A Cl J l V Number and Street or RR L City. or 11.i. Slate Zip TRANSFEREE Name.S`(_0M f rt0L �� r r' ,( '1� An/�Q s'1 4 Address r Number and Stre5t or RR City,I own or 11.0. State Zip Address of Property Transferred G r S i ff 56Q b number aannd,Street or Rit �^ City.Town,or . / plate Zip Legal Description of Property K// l� �W aq )tl 0, IIVI/V� 1. Wells(check one) There are no known wells situated on this property. 0 There is a well or wells situated on this property. The typc(s), location(s)and legal status arc stated below. 2.'So# Waste Disposal(check one) CT There is no known solid waste disposal site on this property. 0 There is a solid waste disposal site on this property,but no notice has been received from the Department of Natural Resources that th, site is deemed to be potentially hazardous. 0 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. Ila rdous Wastes(check one) There is no known hazardous waste on this property. 0 There is hazardous waste on this property and it is being managed in accordance with Department of Natural Resources rules. 4. U1yderground Storage Tanks(check one) IV 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 describ. Blow. 5. 1' ivate Burial Sile'(check one) There arc no known private burial sites on this property, 0 There is a private burial site on this property. The location(s) of the sitc(s) is stated below. The known identifying.information of the decedent is stated below. Information, if any, required by statements checked above: t Attachment for Additional Information? Y/N If so,number of pages `I HEREBY D CLARE THAT THE ORMATION CONTAINED IN PART I OF THIS STATEMENT IS TRUE AND CORRECT Signature: ( rans croror .cnit Telephone Number: PART 11-TO BE COMPLETED BY RECORDER `-.'Date of Instrument IL1`(70 Book/I.D, n 0 � 1 0 5 4 2 Page/I.D. Date-of Recording L ity or ownshipS Deed ❑ County --------------------------------------- ----L---;-------------------------------------- ------------------------------- DNRtorn(July 99) FILE WITH RECORDER 542.0961 INSTRUCTIONS FOR COMPLETING GROUNDWATER HAZARD STATEMENT 3. Hazardous Wastes - "Hazardous waste" is defined in Iowa The transferor of real property is required to complete Part I of this form. The purpose of the statement is,to satisfy legal requirements Code sec's refereion nced ed 41 ltlteteiu.l It is(generally defined as waste ''4for filing instruments of conveyance of real property with the regulation 'county recorder(Iowa Code Section;558.69). The Department of that poses a threat to human, health or the environment. It �Nalural Resources does not approve or disapprove of property includes wastes,which,arc ignitable, corrosive, toxic, explosive, —transfers based on these statements. The statement must be signed violently reactive, psci(4011 listed as hazarous ill the LdXCLUDED afire by one of the, persons transferring the property interest or that of F bulatio person's agent. An agent signing this form represents the household wastes, agricultural wastes returned to the soil as 1 information from transferor to be correct. fertilizers or soil conditioners, agricultural chemicals applied•or disposed of by a farmer in accordance with the manufacturer's instructions, triple-rinsed agricultural chemical containers 'To r the most part the information requested is clear (name, rinsate is used as'riiakeup address, etc.). One statement under each of the numbered items disposed of by farmers '(where the`r (1,.2. 3, 4 and 5) must be checked, and iC one or more of the water he tankmiials. Persox and ns lied at lcgally required tte o be aware of statements checked requires the trher ansferor to provide additional spec information, that informations is to be provided in part 1. Relate the hazardous waste laws. additional information to the specific category of facility (well, 4. Underground ound Storage Tanks - "Underground storage tank" etc.) by numbering it with the corresponding number (1, 2, 3, 4, 6 5). :f additional space is needed, type or print it legibly on a means one or ed to mbina Lion of tanks, to contain including accumulation of nd separate sheet or sheets, complete the statements at the end of Part piping 6 I and attach the 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 oil the property, al mcludee11 etrlolthe eumsurface p oducts the andground. hazardous gorated toxicsubstances" materials reasonably precise, such as a specific distance and }, p direction from a landmark or comer 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 form. a. Farni or residential tanks of 1,100 gallons or less capactt} 1, Wells-A"well" is any excavation that is drilled, cored,bored, used for storing motor fuel for noncommercial purposes. Bu augered, 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 heating oil for consumptive use oir tiu 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 all"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. Iowa Code sections 45513.190 and 159.29, respectively, must be g. A {low-through process tank. stated. An"abandoned well" is a well no longer in use or in such h. �Aliquid trporassociated and gal cthering opeines directly related t, ling state of disrepair that continued use is unsafe or impracticable. s g production Abandoned wells are to be properly plugged in accordance with i. tile tank inank sall on or underground a surfs c area co�f the as a basement or mine, i chapter 39 of the rules of the Department of Natural Resources. j pipes connected to the above exclusions. (567 Iowa Administrative Code,Chapter 39) An "agricultural drainage well" is a well constructed for the "Tank type" means the material of construction d(steel, fi reinforced plastic [FRP], or other [specify]), intemalac purpose of draining, or which drains, water from agricultural land Y to an aquifer(underground), excluding drainage tile intakes which external protection such as a protective coating or wrapping, c outlet to the surface. Agricultural drainage wells are required to cathodic protection. be registered with the department by September 30, 1988, and the Identify the capacity in gallons and the substance stored in eac owner of the well and of the land drained by the well are to develop a plan proposing alternatives to the use of the well by tank. July 1, 1998(See Iowa Code Section 159.29.) 5. Private Burial Sites - "Private Burial Site" meads one c 2. Solid Waste - "Solid waste" means garbage, refuse, rubbish more graves containing human remains. For each site tl; transfer and other similar discarded solid or semisolid material. It does not or shall stale the location of the site. For each decedei include dirt,stone,brick,or similar inorganic material used for fill, buried on the property the transferor shall slate all know as long as no other solid waste is included. Sec 567--100.2(455B), identifying information of that decedent including name, date r Iowa Administrative Code (I.A.C.) for further definitions. A death,and date of birth. l "disposal site" is any area on the property on, in, or under which - The oril of solid waste has been disposed, whether or not the disposal is or 6. Filing county recorder whenrrtlte docu�menot to be're co istGledto : was regulated by the department. Recorder shall forward the original to the transferee when t- lftl e tra`nsferoT—or—ageni—has—not—receivec!n9ticc from the recorded instrument is returned. The recorder is not required 1T Department of Natural Resources that the disposal site has been keep any copies: deemed to be potentialiy hazardous, there is no duty to inquire to the department. *Note The land application of sludges or soils resulting from the rcmcdiation of underground storage lank releases accomplished in compliance with Department of Natural Resources rules without a permit is not required to be reported as the disposal of solid waste or hazardous waste. (Sec Iowa Code Section 558.69) 543-05 DNR form(July 99)