HomeMy WebLinkAboutA008 - Groundwater Hazard Statement dated April 24, 1997 REAL ESTATE TRANSFER GROUNDWATER HAZARD STATEMENT
Please read the filing instructlons'on the reverse side BEFORE completing this form:' 1 i
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tl , PART,1 -;TO BE COMPLETED BY TRANSFEROR
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( YP Legibly)
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Dale Cp'oper, Donald i E r' Barber- and
Social Security No.Lc
TRANSFERORName Leariri°a' k` "1Sarber (or Federal`I.D: No`.)�
21,05' ,5,,.. .et .5.t1!Street Ame ! I ril
to
1 ^ Address .- w , Ob,�.O
n r , 1r tQ!,. to S,;A
"` Number and'Stre'et or RR
City,Town or P.O. Zip
;l•< _ n: ,.!:t�,:_: � 1 'Stet@
SocialtSecurity No
TRANSFEREE Name
Vuica'n' Tnc)'ustria'1 1 'ii�erties.' (or!Federal I.D. No ),4'2r.1" 3'8� r8`8f
Subdivision..
ht , rr <uit
Address 2'1'05''S. E� �5t`h'''Stree't, Suite 212 " ` � Ames ia`;raa")"' 'f504710
Number and Street or RR City,Town or P.O. „ . I State. np�t Zip
Address;of.Prop'ertyTransfered,,'1211051`T 2'3;' '2,207 2221 ;' 230911 2325 -'S:E. 5bh' St,reI*t,t:rAm01s.(r
Number,and Street or RR „City,Town or P.O. ' tsth. :;flk. i iir, ': r1t� irit u,Zip
Legal Description of Property. ' S -1 ,: A ttached ,, „
: ,:'1 ' .1'1'., 37!! 1b: 1..... .:I .. . . .• .. ::i;\•,' rr. ,1fi .1:'>i�:lf`
1. Wells (check one) _ !
ER"There'are no known wells`situated on this'-property. ' 'i' rr,i ;: 1,.,�;>',1•.itt..
❑ There isi'a well orl.wells situatedron th`is'property. The type(s);'locatioti(s) and legal sfatrtas'are slated bteio`w.`_
2. Solid Waste Disposal (check one)
a 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 siteis'deemed to be-potehtially,hazardous.
❑ There is a solid waste' disposal site�onirthis property:which has been deemed to be potentially hazardous
by the Department of Natural.Resources.t,The location(s)'of the site(s) is stated below. ,,; •a .)l,;
3. Hazardous Wastes(check one)
.131�.Th•ere is no known haiardous'waste'on this property.
❑ There is.hazardous;waste,on this;property';and,it is being managed'irfaccordance with,Departmentlof Natural
Resources rules. ":'it l;i.. • > ;. nuC>',i;'t:+llrL'"! "' ;t,j':r rla Of brt•;i IGltllluc)i1P&
4. Underground Storage Tanks (check one)
CT- 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, cist3rns and septic tanks, in instructions.);!----I r
❑';There'is an underground'storage tank or'tank's on this property.The typ'e(s):'size(s)'and an'y kn'wivh s`ubkdrice(s)
,, e1,r,1111„1
contained are described below
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Attachment for Additional Information? Y / N If so, number of pages
I HEREBY DCtARE THAT H INFO ATION CONTAINED IN PART I OF THIS STATEMENT IS,TRUE,,! :,;:, !
AND CORR CT.
Signature: �' Agent Telephone Number: (515) 232-3023
(Transfer r or Agent)
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PART II -TO BE COMPLETED BY RECORDER
Date of Instrument �I I -I ! Book/I.D. P
age/I.D.
1' Date of Recording I I I City or T P wnshi .__�� 7Q
/�y
. Deed,:.:. , ❑ plw�1�,�
Contract ❑ Coun ty 5pjr�
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