HomeMy WebLinkAboutA021 - Groundwater Hazard Statement REAL [.STATE TRANSFER -(iROtINI)WAIIiRIIA/ARDS'TA1'ISMI?N'I"
Please read the l iIinp intitruclions on the reverse side BEFORE completing this lbrol.
PART 1 - TO BE COMPLETED BV TRANSFEROR
(Please"Type or Print Legibly)
TRANSFEROR Name CjEO(/S N !)E UEL C)OW 6:II/7- (fneA0jeR7-/0N, LTd
Address Z3 AtIFICAAWC,0 AflF. Zf} Saa/y
Number and Street or RR City Town or P n. State Zip
TRANSFEREE Name
Address
Number and Street or RR City,T—or P.0 State Zip
Address of'Property'transferred
Number and Street or RR OT.1onn,or P O, slate
Legal DescriptionofProperty s f}c TEL /4 kM/ 7`•/oil/ Df3 UNTLE S5 SUBS/I/
�!'IdES, Z-ou�pr
I.Wells(check one)
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.Soli Waste Disposal(check one)
MThere 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)ofthesite(s)isstated below.
3.Ilaz dons Wastes(check one)
ere is no known hazardous waste on this property.
❑ i'here is hazardous waste on this property and it is being managed in accordance with Department of Natural Resources rules.
4. ground Storage Tanks(check one)
he
Un(re 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.)
❑'['here is an underground storage tank or tanks on this property.Thetype(s),size(s)and any known substance(s)contained are described
below.
5.Private Burial Site(check one)
here are no known private burial sites on this property.
❑ There is a private burial site on this property.The location(s)ofthe site(s)is stated below.The known identifying information ofthe
decedent is stated below.
Information,if any,required by statements checked above:
Attachment forAdditional Information?Y/N Ifso,number ofpages
1 HEREBY ACIARE THAT T F FORMATION CONTAINED IN PART I OF THIS STATEMENT IS TRUE AND CORRECT
Signature: - - —-- relephone Number:
trr.arrr�rnr,rE.no - __
F PART I I -TO BE COMPLETED BY RECORDER 0 _ O
Date of Instrument J /O D. Page/I.D.
Date of RRecor in 5 3 Township AOM--S,
Deed CJ (l11''77��Contract ❑ County V
DNR form(July 99) LE WITH RECORDER
(See Instruction#6)