HomeMy WebLinkAboutA016 - Real Estate Transfer - Groundwater Hazard Statement REAL ESTATE TRANSFER - GROUNDWATER HAZARD STATEMENT
Please read the filing inslyd''601an.slon Tile revbrsdAide BEFORE completing this [Grin.
PART I - TO BE COMPLETED BY TRANSFEROR
(Please Type or Pritit Legibly)
1 RANSFEROR Nanle l'! l� of -7 L— r
Address 7-o Ao15 /Ut,� S`30/
um er an !reel or l 1y, own or '. . tale �p
YRANSl!EILLE Name— �L�SS �i ��///4 t 0.1I VrZ2-1l4/��/J r\1
Address late in
um er ml trcel or t t ily, own or 11.0.
Address of Property Transferred L�lc9, z1J LIt ?>dl
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um er an tree!or Tt CRY, own,or 3a .P
Legal Description of Properly
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1. Wells (cliecl(ogle)
4 There are no known wells situated on this property.
❑ There is a well or wells situated on this properly. The type(s), location(s)and legal status are stated below.
Z. Solid Waste Disposal (cileck Otte)
`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[lie Department of Natural Resources that th
site is deemed to be potentially hazardous.
❑ There is a solid waste disposal site oil this property which has been deemed to be potentially hazardous by the Department of Natural
Resources. Vie location(s) of the site(s)is stated below. .
3. Ilazardous Wastes (check one)
771cre is'no known hazardous waste on this property.
O fllere is hazardous waste on this property and it is being managed in accordance with Department of Natural Resources rules.
4. Undel•ground Storage Tanks (cheep one)
p('niere are no known underground storage tanks on this property. (hole exclusions such as small[anti and residential motor fuel tanks
most heating oil tanks, cisterns and septic tanks,in instructions.)
❑ There is an underground storage lank or tanks oil this properly. The type(s),size(s)and any known substance(s)contained are describ
below.
5. Private Burial Site(check one)
There are no known private burial sites on this property.
'❑ There is a private burial site oil this property. The location(s)of the site(s)is staled below. The known identifying.in Orin ion of the
decedent is stated below.
litforlilatlon, if any, required by statements checked above:
Attachment for Additional Itiforniatioti? Yrf so,number of pages - - - ---
I IILRE11y 1) r THAT TI 1 INFORMATION CONTAINED IN PART I OF THIS STATEMENT IS TRUE AND CORREC'
�7` Telephone Number: _ 7'?
Signature:
Fanslcior o - it'
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------------- ---PART II-TO BE COMPLETED BY RECORDER 01 _ ® 4 7 3 6
Date of Inslnnncnt "1 OI Book/I.D. Page/I.D.
Date of Recordin City o Township I �J
Deed >� (PIC act O County
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UNR form (July 99)
------------- PILE WITH RECORDER 541-096
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