HomeMy WebLinkAboutA010 - 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 Name R K & F, L.L.C.
Address 619 E. Lincoln Way, Ames, IA 50010
Number and Street or RR City,Town or P.O. State Zip
TRANSFEREE Name Somerset Subdivision Fourteenth Addition
Address
Number and Street or RR City,Town or P.O. State Zip
Address of Property Transferred
Number and Street or RR City,Town,or P.O. State Zip
Legal Description ofProperty Lot 3, Block 2, Somerset Subdivision Fifth Addition and Parcel A
of Lot 1, Somerset Subdivision Eighth,'Add .tion, as shown on Plat of Survey recorded in the
office of the Story County Recorder as Instrument No. 03-02495 at Slide 157, Page 1.
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)
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)ofthe site(s)is stated below.
a
3. Hazardous Wastes (check one)
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) r
'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)
XThere are no known private burial sites on this property.
❑ There is a private burial site on this property.The location(s)ofthe site(s)is stated below.The known identifying information ofthe
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 DECLARE THAT THE INFORMATION CONTAINED IN PART 1 OF THIS STATEMENT IS TRUE AND CORRECT
Signature:g Telephone Number: (o,G 3
(Transferor or Agent)
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PART 11 - TO BE COMPLETED BY RECORDER.
S �`� a
Date of Instrument � Book/I.D. Page
Date of Recording S ` l..s� �� Township
Deed ❑ ontract ❑ County
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DNR form (July 99) FILE WITH RECORDER 542-0960
(See Instruction#6)