HomeMy WebLinkAboutA017 - Groundwater Hazard Statement Row
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.
TRANSFEROR Name Midland Homes, Inc. _(or Federal I.D. No.) 42-1019955
4949 Westown Parkway, Suite 195, West des Moines, Ia 50266
Address - —
Number and Street or RR City,Town or 11.0. State Zip
Social Security No.
TRANSFEREE Name Bloomington Court (or Federal I.D. No.) 42-1 01 99 5 9
Address 4949 westown Parkway, Suite 195, West Des Moines, Ia 50266
Number and Slrccl or 1111 City,Town or P.O. Stale Zip
Lot 32 and Outlot C in Bloomington Heights, Plat 5, City of Ames, Ia
Address of Property Transfered --
Number and Street or RR City,Town or P.O. State Zip
Legal Description of Properly Lot 32 and 0utlot C in Bloomington Heights Plat 5, City of Ames Iowa
1. Wells (check one)
ff There are no known wells situated on this property.
❑ There is a well or wells situated on this property. The typc(s), location(s) and legal status are stated below.
2. Solid Waste Disposal (check one)
IR 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. gazardous Wastes (check e)
There is no known hazL us waste on this property.
❑ There is hazardous w on this property and it is being m ged in accordance with Department of
'Natural Resources rules.
4. Underground Storage Tanks (check one)
There 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 CORREC .
9 � c
Signalure:� �� i Telephone Number: ( 513 232-6175
(Transicror or Ag t) X d �,�
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/ �j PART II - TO BE COMPLETED BY RECORDER `t/�
Date of Instrument +� f'" ��� Qook/I.D. q� — Page/I.D. '3'7Tq
Date of Recording I -- City r Township 1 "ee E----I
Deed sAfinkl plat' cS)�r
Contract ❑ County
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DNR form (JUN 88) FILE WITH RECORDER 542-0960
(See Instructions, Ifs)