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Home My WebLink AboutA014 - Real Estate Transfer - Groundwater Hazard Statement KL;Ab ESTATE TRANSFER - GROUNDWATER HAZARD STATEMENT Please :cad the filing instructions on the reverse side.BEFORE completing this form. 4 PART I - TO BE COMPLETED BY TRANSFEROR (Please Type or Print Legibly) TRANSFEROR Name V P, C-7(n Address r3 3�j� 2C C�O,C� d um er nn tree[or � City,Town or P fate g,p 1 TRANSFEREE Name CeeLch Address CD um er"Au OUCCE sty, own or P. . rate rp r Address of Property Transferred. um er ao tree[or 1ty, own,or - - fate rp Legal Description'of Properly S e Cosh 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) rfT 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 Resou site is deemed to be potentially hazardous.- rces that t] ❑ 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 propertyand it is being managed in accordance with Department of Natural Resources rules. 4: Underground Storage'ranks(check one) 'There are no known underground storagri tanks on this roe ,. P P rh'• (Note exclusions such as small farm and residential most heating oil tanks, cisternsmotor fuel tanks 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 desc' '1 below. �, S. 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 locations)of the site(s)is stated below. The known identifying information decedent is stated below, g on of the Information,if any,required-by statements checked above: LL/Lt.//� �R h 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 UE AND CORRECT ( rans eror or gcnq Telephone Number: 5/ p2 3;k - 8-/(� --------------------------- - - PART H-TO BE COMPLETED BY RECORDER ------------------------------ Date of Instrument_ Z Book/I.D. 01 Page I.D. Date of RecordinK�� `� l�t`0-�� City o wns ' Deed ❑ Contract ❑ County DNR form(July 99) ---------------------------------- -------------- - FILE WITH RECORDER --- ------------------------------------------------- ' (See Instruction#6) 542-0960 INSTRUCTIONS FOR COMPLETING GROUNDWATER k1AGAtu►J' `" u•lr,•-��r® 02 It this I A.C., and federal " complete.Part I of 3. �Iazardous Wa��1. 567aZ141.2 (4558), ►s de ul d • eror of real property is required to eompl Code section 455B. generally defined as waste I [le transf nn- 'I7ie purpose of the statement is to satisfy legal requirements re ulations referenced therein. It is b that poses a.threat to human health or the env that it filing instruments of conveyance of real TheDe artmentloC g P includes wastes which are ignitable, corrosive, wally recorder.(Iowa Code Section 558:69). eciCt'cally lislcd as hazardous in the Codc p rove or disapprove of property violently reactive,or sp EXCLUDED are lateral Resources does not a p of rederal Regulatioris (4.0.- CPR 26l). ansfcrs based on these statements.'The statement e l°t interest or thatlied o: the per transferring the p P y escnts the household wastes, agriconte sal agricultural chemicals app to tile oil r' 'y one'of p agent signing this form repr �erson's agent-. An ab g fertilizers or soil conditioner , from transferor to be correct. disposed of by a farmer'ill.accordance with the manufacturer': nforrnation. tri le=rinsed : agricultural 'chemical container: instructions, P uested _is clear (name, disposed of by farmers.,(where the rinsale is used as n�akeul art the. information,req, lied at appropriate rates),.and othe For the most p water in the tankn�ix and app address, etc-). One statement undeaea�id°f oltctormmorc of the P specific materials. Persons are legally required 10 be aware o (1, 2, 3, 4 and 5) must be check provide additional wires the transfcror to p art 1. Relate the Hazardous waste laws- statements checked req storage tank information,that information is to provided in of facility (well, --additional_information to the sp ' cific category, q, Underground Storage'Tanks - "Underground numb of tallks, ering it with the corresponding nuLlttele libly on4a means one or a co mbt aiks�used to contain inclea rlaccutmulatio nno etc.) by c or print g i in connected erccnj c 5)- if additional space is needed, type ulated substances rc�ulatcd substance s, and chi volume of which is i p separate sheer or sheets, completeltajiohc n to►alltcopicsloC►tl e form P bre beneath the:surface of the ground. "Re or toxic matcria: I.and attach the additional mCorn o►n the propert', be more include petroleum products and Hazardous When describing• the location of a facility general and Underground storag . . reasonably precise, such as a specific distancetl eproperty- A identified itt 5G7-=135.2(45i5B); I.A.C. g r tank does not include: direction from a landmark or corner o 100 gallons or less capacr professional survey is not necessary- Tle following definitions are a Farm or residential tanks of 1, purposes- 13 for use in completing the form. 'lied cored,bored, used for storing motor fuel for noncommercial pure `well" is any excavation that is drilled, See 455B.473(4)) tive use on tl I, Wells-A` heating oil for consume washed, driv"en, dug,jetted or otherwise constructed for he b Tanks used for storing angered, premises where stored.:: accessing groundwater .or forvvells diverting does notcincludeja° c Residential... tanks:' ground, including abandoned =ulated by state or federal law. d• pipeline facilities re[, it pond,or lagoon. `:open ditch or drainage tits.which dischargeao the surface. e A surface impoundment;p P system- or drainage well," I a well is an"abandoned well" or ass of the well with respect to f. A storm water or wastewater collection sy A flow-tllrougli process tank. this must be identified and the state respectively, must.be 9. liquid trap or associated gathering lines directly related Iowa Code sections 4558-190 and 159.29, p q. P gathering operations. longer in use or in such oil or gas production and g stated. An"abandoned well' is a well no long impracticable. disre air that continued use is unsafe oaccordance-with— — i•A tank in an unda�ovc tle surface such the floor as a ' or mine state of P plugged to the tank is ono , Ab !ndolled „,ells arc to be properly rin►ens of Natural Resources. j Pipes connected to the'above exclusions. chapter 39. of the rules e the ,Chapter steel, fibergl Chapter 39). (567 Iowa Administrative Code, ,.Zak type means the m4terial of construction(.steel, or other.[specify]), and any In constru agricultural land reinforced plastic[FRP], projective coating'or wrapping. An "agricultural�,drainage well" is waterllfrom ag iced for the external Protection such'as a p or which drains, P purpose of draining, drainage the intakes which cathodic projection. under round),excluding g are-required to to an aquifer•,( g • outlet to the surface. Agricultural drainage wells arc req and die September 30, 1988, Identify the capacity in gallons and the substance stored ul ei be registered with the department by p ained by the well are to tank. Owner of the well and of thernativesrto the use of. the well by develop a plan proposing alt "Private Burial Site" means ont July 1, 1998 ( 5. Private Burial Sites - See Iowa Code Section 159.29•) raves containing human remains: For each site i more g „ ' refuse, rubbish. d Waste - "Solid waste means garbagecrial. Ij does not transfcror shall stale llnc location oC the site. For each ece� 2. Soli buried on the property the transferor shall state all krn and other similar discarded solid or semisolid mat include dirt,stone,brick,or similar inorganic material used 45513), for rill, identifying information iliac decedent including name; at as-long as no other solid waste is iriclu for further definitions. A death;and date of birth- Iowa.Administrative Code (I.A.C.) or under which » st be area on the property o►1, in, 6, Filing - The original of this form be recorded ispresetfiledted to "disposal site is any ar whether or not the disposal is or county recorder when ttie documen colid waste has been disposed, was regulated by the department Recorder shall merw.rit s,- turned.original tThe to tile transferee not r quit � recorded ins If the transferor or age nt has not received notice from the keepany copies. De artment of Natural Resources that Qieid►no duty tosposal cinqu as be to P there deemed to be potentially hazardous, the department- *Note The land application of.sludges or soils resulting from the ' lishe rcmediation of underground storage uralc releases Resources rut sewithoutta compliance with Department of N l permit is not required to be reported as the disposal of solid waste or hazardous waste. (See Iowa Code Section 558.69) DNR form(July.99) '