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HomeMy WebLinkAboutA009 - Real Estate Transfer - Groundwater Hazard Statement 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 The City of Ames,Iowa SSN/EIN 42-6004218 Address 515 Clark Avenue Ames Iowa 50010 Number and Street or RR City,Town or P.O. State Zip TRANSFEREE Name Water Tower Place Subdivision Address 24th Street and Hoover Avenue Ames Iowa 50010 Number and Street or RR City,Town or P.O. State Zip Address of Property Transferred Number and Street or RR - City,Town,or P.O. State Zip Legal Description of Property One square acre in the Southeast corner of the Northeast quarter of the Northwest quarter,Section 34 Township 84 North,Range 24 West of the 5th P.M.Story County Iowa 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. 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 ddemed 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) IS 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) ■ 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) ■ There 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 THAT THE INFORMATION CONTAINED IN PART 1 OF THIS STATEMENT IS TRUE AND CORRECT Signature: Telephone Number: 515-239-5150 Tom Neumann (1'ransreror or Agent) ---------------------------------------------------------------------------------- PART II—TO BE COMPLETED BY RECORDER � Date of Instrument--A—_), Book/I.D. , a Page/I.D. Date of Recording_ d� —®� City r Township Deed� Contract ❑ County SLO r C.� --------pfa-6--------------------------- ------------------------------------------------- DNR Form(July 99) FILE WITH RECORDER 542-0960 (See Instruction#6) Water Tower Place Subdivision-Groundwater Hazard Statement-021502 '