HomeMy WebLinkAboutA010 - Real Estate Transfer - Groundwater Hazard Statement TRANSFER - GROUNDWATER HAZARD 'STATEMENT
Please read the filing instructions on (lie reverse side BEFORE completing this form.
PART I - TO BE COMPLETED BY TRANSFEROR
(Please Legibly)
Type or Print Le
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TRANSFEROR Name � W S,WU�Q L 1 N 04 (' ((Jx
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Address P er in ireel or _ M�
11 own or
a
tale ,1,
TRANSFEREE Name
Address
om er au tree)or
tale
Address of Property Transferred
um Cr an treel or
11Y, own,or ,
tale ,P
Legal.Description of Property
-a Vj
I. Wells(check one)
l\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.
.Solid Waste Disposal fcbeck 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
site is deemed to be p been received from the.De ariment
1 otentially hazardous.
❑ There.is a solid waste disposal site on thisproperty.which leas been deemed to be Potential] p of Natural Resources that ll
Resources. The]ocation(s)of the site(s)is stated elow P Y hazardous by the Department of Natural
3. Hazardous Wastes(check one)
IR 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
.4. Underground Storage Tanks(check one) Resources rules.
There are no known underground storage tanks on this property, (]Vote exclusions such as small fa
most heating oil tanks, cisterns and septic tanks, in instructions.)
❑ There is an underground storage tank or.tanks on this property. .Tlre t e s size(s)and an know rm and residential motor fuel tarilcs,
below, YP Or y n substance(s)contained are dcscrib
5. Private Burial Sile'(c)reck one)
AK There arc no known private burial sites on this property,
❑ There is a.privale burial.site on this property. The locations)of the sites)is slated below.
decedent is stated below.
The known identifying-information of the
,formation; if any, required by statements checked above:
1
ttaclunent for Additional Information?
}'/N If so,number of pages .
EIEREBY D.CCLAI TII
HE INFORMATION CONTAINED IN PART I OF THIS STATEMENT IS TRUE AND D CORRECT
( tans cror or cn1)
Telephone Number:
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PART II-TO BE By RECORDER
tte of instrutnent�� ----------------
Book/I.D,
Itc of Recording "� Page/I.D.
-�
City r Townslti
:cd ❑ Contract ❑ County.
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VR form(July 99) ---------------=- ---- ------------
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FILE WITH 1 1 - -----------------
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