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Home My WebLink AboutA025 - 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 Name Convalescent Home for Children Foundation, Inc. Address 5900 Pioneer Parkway Johnston IA 50131 Number and Street or City,Town or P.O. n State Zip TRANSFEREE Name W Gt �' rr�,lJ`I 1.t51 •�.. - Address Number and Street or RR City,Town or P.O. State Zip Address of Property Transferred Not-Assigned - -- — _ Number and Street or RR City,Town,or P.O. tate Zip Legal Description of Property Walter Family Campus Subdivision, an Official Plat, now included in and forming a part of the City of Ames, Story County, Iowa. 1. Wells(check one) XX 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. Solid Waste Disposal(check one) XXThere 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) ' VThere 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. Underground Storage Tanks(check one) XKThere 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 describe below. 5. Private Burial Site(check one) XN There are no known private burial sites on this property. ❑ There is a private burial site on this property. 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 pages I HEREBY DECL E TIL4T H F ION CONTAINED IN PART 1 OF THIS STATEMENT IS TRUE AND CORRECT Signature: (Transferor or Telephone Number: _(5� 225-3737 gent) MicgK-------------------------------------- ---el J. Greeno Agent- ----------------------------------------------------- - ----------- PART II-TO BE COMPLETED BY RECORDER Date of Instrument Zo1 71cV2V Book/I.D. Page/I.D. �I Date of Recording `\ �Tn>a ownshi ..•J 0 19 �`9 Deed ❑ Contract ❑ County -------------------------------------------------------------------------------------------------------------------------------------------------------------------------- DNR form(July 99) FILE WITH RECORDER 542-0960 (See Instruction#6) INSTRUCTIONS FOR COMPLETING GROUNDWATER HAZARD STATEMENT 'he transferor of real property is required to complete Part I of this 3. Hazardous Wastes - "Hazardous waste" is defined in Iowa brm. The purpose of the statement is to satisfy legal requirements Code section 455B.411, 567--141.2 (455B), I.A.C., and federal or filing instruments of conveyance of real property with the regulations referenced therein. It is generally defined as waste :ounty recorder (Iowa Code Section 558.69). The Department of that poses a threat to human health or the environment. It Jatural Resources does not approve or disapprove of property includes wastes which are ignitable, Arrosive, toxic, explosive, ransfers based on these statements. The statement must be signed violently reactive, or specifically listed as hazardous in the Code )y one of the persons transferring the property interest or that of Federal Regulations (40 CFR 261). EXCLUDED are )erson's agent. An agent signing this form represents the household wastes, agricultural wastes returned to the soil as nformation from transferor to be correct. fertilizers or soil conditioners, agricultural chemicals applied or disposed of by a farmer in accordance with the manufacturer's 'or the most part the information requested is clear (name, instructions, triple-rinsed agricultural chemical containers iddress, etc.). One statement under each of the numbered items °disposed of:by farmers (where the rinsate is used as makeup 1, 2, 3, 4 and 5) must be checked, and if one or more of the water in the tankmix and applied at appropriate rates), and other ;tatements checked requires the transferor to provide additional specific materials. Persons are legally required to be aware of nformation,that information is to be provided in part I. Relate the hazardous waste laws. additional information to the specific category of facility (well, ,tc.) by numbering it with the corresponding number (1, 2, 3, 4, 4. Underground Storage Tanks - "Underground storage tank" i). If 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 Part piping connected to the tanks,used to contain an accumulation of 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 on the property, be more beneath the surface of the ground. "Regulated substances" .-easonably precise, such as a specific distance and general include petroleum products and hazardous or toxic materials iirection 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 form. a. Farm or residential tanks of 1,100 gallons or less capacity 1. Wells -A"well" is any excavation that is drilled, cored,bored, used for storing motor fuel for noncommercial purposes. But 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 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. Iowa Code sections 45513.190 and 159.29, respectively, must be g. A flow-through process tank. stated. An"abandoned well" is a well no longer in use or in such h. -A liquid trap or associated gathering lines directly related to state of disrepair tliat continued use is unsafe or impracticable. oil or gas production and gathering opexations. Abandoned wells are to be properly plugged in accordance with i. A tank in an underground area such as a basement sources: or mine, if _- — the tank is on or above-the surface'of the floor. chapter 39 of the rules of the Department of Natural Re - — — 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(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 1, 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 each site the and other similar discarded solid or semisolid material. It does not transferor shall state 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 date of birth. "disposal site" is any area on the property on, in, or under which solid waste has been disposed, whether or not the disposal is or 6. Filing - The original of this form must be presented . The the was regulated by the department. county recorder when the document to be recorded is filed. Recorder shall forward the original to the transferee when the If~the transferor or agent has not received notice from the rccorded-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 from the K. remediation of underground storage tank releases accomplished in t. '` ;T �: compliance with Department of Natural Resources rules without a permit is not required to be reported as the disposal of solid waste f or hazardous waste. (See Iowa Code Section 558.69) C) 0) C> 543-0960 DNR form(July 99)