HomeMy WebLinkAboutA014 - Groundwater Hazard Statement dated October 30, 2001 REAL ESTATE TRANSFER - GROUNDWATER HAZARD STATEMENT
Pleasc read the filing instructions on the reverse side BEFORE completing this form.
PART I - TO BE COMPLETED BY TRANSFEROR
(Please Type or Print Legibly)
TRANSFEROR Name
Address �. /( �,IU4
Nuffiber and Strecl or KR Cay.I own or PW tale Lip
TRANSFEREE Name_ 30301 Ul IN) O#WSE,V
Address
urn er and Street or RR City,I own or P.O. Slate Zip
Address of Property Transferred
Number and Strcel or RR City.Town.or M. SIAM Zip
g P Property
Legal Description of Pro crt
1. Wells(check one)
There 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)
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 th
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. Hazardous Wastes(check one)
LVThere 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. Un erground 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 describ
below.
5. 2te Burial Sile'(check one)
7There are no known private burial sites on this property.
O There is a private burial site on this property. The localion(s)of the sites)is stated below. The known identifying.information of the
decedent is stated below.
Information, if any, required by statements checked above:
Attaclunent for Additional Information? Y/N If so,number of pages
i
I HEREBY DE THAT TH 911AIATION CONTAINED 1N PART 1 OF THIS STATEMENT IS TRUE AND CORRECT
Signature: Telephone Number: _ Z 3 2 6 1 7S
raps cn r 'cnq
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PART II -TO BE COMPLETED BY RECORDER
I Dale of Instrument 16, Book/I.D. Page/1:Da 1 1 4 8 48
Date of Recording City or Township
Dcca'%' Contract ❑ County
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DNR form(July 99) FILE WITH RECORDER 542-096c
(Sec InOnlclion#h)
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