HomeMy WebLinkAboutA014 - Groundwater Hazard Statement REAL ESTATE TRANSFER -GROUNDWATERHAZARDSTATEMENT
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)
TRANSFERORName Bloomington Heights West Townhomes,L.C.
Address 2503 73rd Street,Urbandale,Iowa 50322
Numbs and Sued or n City,Town or P.O. shh zip
TRANSFEREE Name Bloomington Heights West Townhomes Plat 1,Ames,Story County,Iowa
Address
Number god street or n (Sty.Town or P.O. swe tip
Address of Property Transferred
Number and Sued or n tXty,Town,or P.O. shh vP
Legal Description of Property. Lots 13 -3 8 and Outlot A in Bloomington Heights West Plat 1,Ames, 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)
1N 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)
CKThere 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)
1g 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 Info � If so number of pages
I HEREBY DEC7AETHATTHC ION CONTAINED IN PART i OF THIS STATEMENT IS TRUE AND CORRECT
- 515-270-1497
Signature: Telephone Number:
(rrodryr"er aQ
John D.Gamble, S tary
PART 11 -TO BE COMPLETED BY RECORDER
Date of Instrument Book/I.D. Page/I.D.
Date of Recording City or Township
Deed ❑ Contract ❑ County
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DNR form(July 99) FILE WITH RECORDER 542.olw
(See Instruction#6)