HomeMy WebLinkAboutA016 - 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. cC1�
TRANSFEROR NameL� r J' + �` P( (or Federal I.D. No.)F" 63T gnlu*-s :114 —S r�
Address
Number and Street or RR City,Town or P.O. State Zip
) 2� Social Security No.
TRANSFEREE Name. i' 6G S���ti/i-S/Vl Z� (or Federal I.D. No.)
Address
Number and Street or RR City,Town or P.O. State Zip
-77
Address of Property Transfered r in<'J
Number and Street or RR City,Town o P.O. State Zip
Legal Description of Property ( �r `� ( J n� c �u �J `4 U� �z' d &1a-C
1. W. ells (check one)
b-'-here 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)
%,,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. Hazprdous Wastes (check one)
i'YThere 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. Un3id/rground Storage Tanks (check one)
DIThere 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 described below.
Information, if any, required by statements checked above:
Attachment for Additional Information? Y /N If so, number of pages-:.
I HEREBY DECLARE THAT THE INFORMATION CONTAINED IN PART I OF THIS STATEMENT IS TRUE
AND CORRECT.
Signature.: �� - a-�Iut' � i' � Telephone Number:
(T ansferor or Agent)
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(PART II -TO BE COMPLETED BY RECO/R_D/ER
Date of Instrument [ Cy/d D Book/I.D. �CO(O Page/I.D.
Date of Recording ` City r Township
Deed EK P10
Contract ❑ County
DNR form (JUN 88) FILE WITH RECORDER 542-0960
(See Instructions, #5)