HomeMy WebLinkAboutA013 - 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 Namc
S-4 AM-to'
Number and Slrca or RR City,Town or P.O. Shale Zip
TRANSFEREE Name
Address
Number and Street or RR City,Town or P.O. Stale Zip
t'-
Address of Property Transferred
Number and Slica or RR City,Town,or P.O. State Zip
Legal Description of Property
1. Wells (check one)
Thcrc arc no known wells situated on this property.
❑ here is a well or wcl Is situated on this property.The type(s),location(s)and legal status arc statcd below.
2.Solid Waste Disposal(clieck one)
XThcre 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 sites)is stated below.
3. Hazardous Wastes(check one)
CK here 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 arc no known underground storage tanks on this property.(Note exclusions such as small farm and residential motor fuel tanks,
%lost Beating oil tanks,cisterns and.septic tanks, in instructions.)
❑There is an underground storage tank or tanks on this property.The type(s),sizes)and any known substance(s)contained are describe
below.
S. Private Burial Site(check one)
Thcrc arc no known private burial sites on this property.
❑ There is a private burial site on this property.The location(s)of the sitc(s)is stated below.The known identifying information of tlic
decedent is stated below.
Information, if any, required by statements checked above:
Attachmcnt for Additional Information?Y/N If so, number of pages
[ HEREBY DECLARE TII INFORMATIO CONTALNED IN PART I OF THIS STATEMENT IS TRUE AND CORRECT
Signature: Telephone Number: ,�_Il•��2 32— Z
(Tnmlero or Aptol
PART I 1 -TO BE COMPLETED BY RECORDER
Date of Instrument Book/I.D. Pagc/I.D.
Date of Recording City or Township
Deed 0 Contract ❑ County