HomeMy WebLinkAboutA029 - Real Estate Transfer - Ground Water Hazard Statement r '
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)
TRANSFEROR Name _ /
Address �/ / J�) /L JbL4 — ( dd
Number and Street or RR City,Town or P.O. Slate Zip
TRANSFEREE Name (ff
Address
Number and Street or RR City,Town or P.O. State Zip
1
Address of Property Transferred
Number and Slice(or RR City,Town,or P.O. Stale Zip Legal Description of Property
#�
I. Wells (check one) ^ � t� 7p-yl ;A_
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.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 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.Hazardous Wastes(check one)
There 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. Underground Storage Tanks(check one)
J$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.
5.Private Burial Site(check one)
,KThere 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 of the
decedent is stated below.
Information, if any,required by statements checked above:
Attachment for Additional Information?Y/N If so,number of pages
I HEREBY DECLARE TH INFORMATI CONTAI 1 OF THIS STATEMENT
�IS/TRUE AND CORRECT
Signature: Telephone Number: `�r �3 z� 9(73 Z
(Transferor a Agent)
�_)/
PART I 1 -TO BE COMPLIWF.A BY ILEC
Date of Instrument I D� r
R Book/I.D. � Page/I.D.
Date of Recording I 14 6'�' City r Township
Deed 41
Contract ❑ County �aq
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DNR form (July 99) FILE WITH RECORDER
502-0940
(See Instruction#6)