HomeMy WebLinkAboutA027 - Groundwater Hazard Statement REAP. ESTATIP `fRANSVM -GROUNDWATERHAZP"IDSTATEMENT
Please read the fiu.ig instructions on the reverse side BEFORE c...npleting this form.
PART I - TO BE COMPLETED BY TRANSFEROR
(Please Type or Print Legibly)
TRANSFERORName Ames Land Company,L.L.C.
Address 2530 73rd Street,Urbandale,Iowa 50322
Number and Street or RR City,Town or P.O. state tip
TRANSFEREE Name Bloomington Heights West Plat 1
Address Ames,Iowa
Number and Street or RR City,Town or P.O. swe tip
Address of Property Transferred Ames,Iowa
Number and Street or RR City.Town,or P.O. state zip
Legal Description of Property Outlot"W" in BLOOMINGTON HEIGHTS PLAT 9, an Official Plat, Ames, Story County,
Iowa.
1. Wells(check one)
EK 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)
M 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)
(f 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)
lX 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)
EK 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 ARE AT TH NFORMATION CONTAINED IN PART 1 OF THIS STATEMENT IS TRUE AND CORRECT
Signatur Telephone Number: (515)270-1497
aederor Agent)
John D. Gamble, S etary
PART 11 -TO BE COMPLETED BY RECORDER
Date of Instrument I l o� Book/I.D. Pa e/iG.
l o� g
Date of Recording Q�, City o ownship
Deed� P
-Contract ❑ County (Itbtll ftes
DNR form (July 99) FILE WITH RECORDER 542-OM
(See Instruction#6)