HomeMy WebLinkAboutA007 - Real Estate Transfer - Groundwater Hazard Statement . . . .
RICALE8�U&'U'0 'I'QAN8FDR (WUi)N|)\V0l]< HAZARD STK[[WE'NT
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Legal Description n[Properly CAJLJ_7- _ >C~ _ 5 L'/8"P1/// 0_Aj
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1Oiero are no known wells nimu(c'| oil (his property.
D ]6cpo isuvoU nr wells situated oil ||liopvopooy. The (ypc(o). |vo(ioo(s)uuJ |ogx| o(umo are stated below.
Z. Gv| c Disposal (rh,,k"x,)
�xo known solid nogxJ�pmo) sihoo pro
perty.
-[1 There is a solid waste disposal site oil this pf opel ly, bill lio lio(icc lias been I eceived I'l"m tile Department"[Natural Resources that the
site ixJxo/ncJNhnpo|ou(iaUyhazardous.
U There'is u solid waste disposal oi|cox this pnUedy which has |ucu'|ccxxc | (obe potentially\uzuo]uuohytile Department o[Natural
Resources. The knx<im (o)o[||m xixXx) is mo(cJ\n|ov'.
] "Vu*tcx (uhooi( vnc) ^ ^
,01 'I'liere is ho known hazardous waste oil (his property. ^ '
(l There ixbozunloox waste oil this property and i( iskoiog managed iu accordance nidh Dopa/h000to[Natural Resources m|u�. .
4 Tu"kn(check one)
��T6cro um no known onJcrgpnonJ xhmX ' tanks oil this po^yo(y. (Note oxc|xuimm such as small [unn and moiJcohu| motor fuel uukx
o
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~ nm�lieu(ingo6| tanks, cisterns onJoqxic tanks, ix imomztkmo]
[| There is all um|or8vnonJ xivmge lank or|uoko nn A/ix pnY ody. The |ypo(o), size(s) and any known mu6x/oxcc(o)conuillrdmedescribnd
hckxv.
71".1' x] S|Yc(chook vnc)
� xc�k�� pi,uh��o\xius � U'� pmym(y.
Thnr is privateburial site oil this property. The local im (s) o[ lie dk(x) iyduteJbelow. ]lieknnwui(leo(iFvingixf'oonud000[tlie
decedent is stated below.
ln6ocmotinn, if any, nqoiuJbystatements c|`cxkoJ above:
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Attachment for Additional Information? Y/N |[m.. xoxJnro[pnges_ ___
X x IN PAR[ 1 #FTyQSSTAT0m1ENT X8TlMR AND CORRECT
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DNR6x/x(Jo|vYo)` . FILE WITH RECORDER 542-0960
(S,rhmnmim' 0o)
. ^ . .
INSTRIIC LIONS FOR COi111'I.ETING GROIINI)WATER IIA%ARU STA7TEMEN'k' .
The transferol.oheal properly is required to cluiplele fart I ol'this 3. Ilazardous Wastes - "Hazardous wade" is defined in Iowa
linni. The purpose ol'(he slalenenl is to satisly legal requirements (title seclion 45.513.411, 567--I.11.2 (45513), I.A.C., and federal
for filing inslrtulicnls of conveyance of real propely with file re6ulalions rcicrelced Therein. It is generally defined as waste
county recorder (lowa Code Section 558.09). The Ihparlment of Ihal poses it threat to human health of the eiviroumicnt. It
Natural Resources does not approve of disapprove (lf properly includes wastes which are ignitable, collusive, toxic, explosive,
transfers based on these slit lei nenIs. The slatenncnt moist be signed violently reactive, or specifically listed as hazardous in the Code
by one of the persons ,transferring II(c„pr(iporty interest or that of -Federal , Regulations (40 CFR 261). I XCL,UDED are
person's agent. An agent signing this form represents the household wastes, agricultural wastes ietorned to the soil as
inliirnlalion Irom.lransfcror to be correct. Fertilizers (?I.. Soil 'condilioners, agricultural chemicals applied or
disposed of by tt farmer in accordance With file nianufaclurer's
For (he most part the information requested is clear (manic, instructions, triple-rinsed agricultural chemical containers
address, etc.). One slalenient under each of the numbered items disposed of by farmers (where the rinsate is used as makeup
(1, 2, 3, 4 and 5) must he checked, and if' one or nine of the water in the lankiuix 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
infitrnla(ion, that infinniation is to be provided in pall 1. Relate (he hazardous wa,lc haws.
additional infornrition to (he specific category of facility (Well,
etc.) by numbering it with the corresponding number (I, 2, 3, 4, 4. Underground Storage Tanks - "1Indcrgiouud storage lank"
-5). If' additional space is needed, lyp,r m print it legibly on a cleans ume or a conibinalion of tanks, inelliding i.indcrground
separate sheel or slicers, complete the slatenicnls nt the cad of"I'arl piping connected to the tanks, used (o contain an accumulation of
I and attach the additional imfilrnlalion (o all copies of the limn. rcgulalcd substances, and (he voluule 01' which is 10 percent or
When describing the location of a facility oil (he property, he more beneath the surface of the ground. "Regulated substances"
reasonably precise, such as a specific distance and general include petrolellin products and hazardous or toxic materials
direction froni a landmark or corner of' the property.i A ideutificd 'n. 567- 135..2(45513), LA.C. Underground storage
professional survey is not necessary. The Billowing dclinilions are tank does i of include:
I'm use in completing the I61ill.
a. Farm or reside ial tanks of 1,100 gallons or less capacity
1. Wells- A "well" is any excavation that is drilled, coral, hored, used for storing fit( or Fuel file noncommercial purposes. 13ul
angered, washed, drivel, slug, jetted or otherwise constructed fiir Sec 115513.473(4))
accessing groundwater or for diverting surface water into the h. 'Tanks used fiir storing I eating oil For consumplive use on the
ground, including abandoned wells. "Well" does not include all preuiscs where stored.
open ditch or drainage tiles which discharge to the surface. c. Residential septic tanks.
d. pipeline facilities regulalcc by slate or ledcral law.
If a well is an"abandoned well"or an"agricultural drainage well," c. A surface inllotln(In)ent, pit pond, or lagoon.
this plus( be identified and the status of file well Willi lespcct to f. A storm wafer or was(ewa(er(ollec(ion system.
Iowa Code sections 45513.190 and 159.29, respectively, into be g. A flow-Through process lank.
stated. An "abandoned well" is a well no longer in use or ill such It. A liquid trap or associated gathering lines directly related to
shale of t.lisrepair that continued Ilse is unsalc or impracticable. oil or gas production and galhc ing operalions.-
Abandoned wells arc to he properly plugged in accordance with i. A tank ill lit underground area such as a baseiiient or mine, if
ehal°,lei-3�t—of-thy rtrirs (:ruler ik�,'.n'tiillait-OtiVillm ii—L�CSilirl�'� lliti-llrlll is(irr(irATovi=rilirs[n', uil f iu-fi�liir-
(567 Iowa Administrative Code, Chapler 39) j. Pipes connected to the above exclusiolls.
Ali "agiicullmal drainage well" is a well constrticicd fur (he "'Tank lypc" nicans the material of construction (steel, fiberglass
purpose of,draining, or Which drains, Water li-onl agricultural land reinforced plastic IFRI11, or other [specilyl), and any internal or
to an aquifer(undeigromid), excluding drainage life intakes which external prolection such as a protective coaling or wrapping, or
(little( to the surface. Agricultural drainage wells are required to cathodic protection.
he legislered will, file depantnnent by September 30, 1988, and the
owner of the well and of the land drained by the well arc to Identify the capacity in gallons and the substance stored ill each
develop a plan proposing alternatives to the use of' file well by (auk.
.duly I, 1998 (See Iowa Code Section 159.29.)
5. Privale Burial Sites - "Private Burial Site" means one (it-
2. Solid Waste - "Sulii`I ��'islc" iueans garbage, refuse, rubbish more graves conla ill ing" htinlan remains. For each site the
and other similar discarded solid or semisolid material. If dues not transferor sludl state the location of the site. For each decedent
include flirt, stone, brick, or similar inorganic malcrial used fiir I'll(, buried oil the property the transferor shall slate all known
as long as no other solid waste is included. See 567--100.2(,15513), identifying i iliirnialiou of'that decedent including name, date.or
Iowa Administrative Code (I.A.C.) for fin-Iher definitions. A deallu, and dale of,birth.
"disposal site" is any area on the properly on, in, or under which
solid Waste has been disposed, whether or not the disposal is or 6. Filing - The original of this Dorm nuts( be presented to the
was regulated by the department. county recorder whell the document to be recorded is filed. The
Recorder shall fin-ward flue original to (he transferee when the
It (tic-Gansfe?or or agedhas nil received notice Jfronn iGe — rccurdc(I inslrumcnl is relurncil The recorde is not rcyuircd to
Department of Natural-l(eso roes that the disposal site has been keep any copies. :=:•i. - a
dCeilied to be poleltially hazardous, Ihe'e is no duly to iugllire to
file department.
*Note The land application of sludges or soils reselling from the
remediation of underground storage lank releases accomplished in
compliance with Department of Natural Resources rules without it
permit is not required to he reported as the disposal of'solid waste
or hazardous waste. (See Iowa Code Section 558.69)
1
DNR ronn(July 99) su.oao