Loading...
HomeMy WebLinkAboutA010 - Real Estate Transfer - Groundwater Hazard Statement REAL ESTATE TRANSFER- GROUNDWATER HAZARD STATEMENT Please read the filing instructions on the reverie side BP.RORE completing this Corm. ® PART I -TO BE COMPLETED BY TRANSFEROR (Please Type or Print Legibly) TRANSFEROR Name J-Af"ES cieo7A/- S/L✓Eea00 AA+NCH mod'74zef live. Address 61221 /VoeWl- FORK20. A•mES e�t« er. ono«P.O. TRANSFEREE Name S7'EVEN W. k1sam, Address 4-30 40DCW800 PR- q-` XS ZA S©v/O Address of Property Transferred 212.3 0/0p I L- /2•iO(21E R/7. A-A" Fji -T-,` Soo/o Legal Description of Property C D? 32 CD/J/V712✓ ES K-4 e-S VFV13 01 Vt r1 D1V /F 7H .A /,O/7/n/1/ 7t, eJ 7O/Z✓ WU/V2'T— Z 6?WA .. 1. Wells(check one) There are no known wells situated on this property. U 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 thth 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 Natttral Resources. The location(s)of the site(&)is stated below. Q 3. Hazardous 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. Underground Storage Tanks(check one) Tbeyn are nn 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 substances)contained are deslenbed below. 5. Private Burial Site(check one) XThere 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 off he 'decedent is stated below. Information,if any,required by statements checked above: e 4 � Attachment for Additional Information? Y h] -If so,number of pages I III;REBY DECLARE—THAT7TO�ZONON AINED 1N PART I OF THIS STATEMENT IS TRUE AND CORF9XT Signature . �Lt.� Telephone Number: _ ' 2✓�2 Z/ZQ nu a«or tmr PART El-TO BE COMPLETED BY RECORDER ® 1 2 49 Date of Instrument 01 — I - O ' i18107D• S QDate of Recording a^( _01 c �e`City or ownship �(rh — Deed ❑ Contract ❑ County DNR form(July 99) MLE WITH RECORDER (See Instruction q6)