HomeMy WebLinkAboutA012 - Real Estate Transfer - Groundwater Hazard Statement REAL ESTATE TRANSFER - GROUNDWATER HAZARD STATEMENT
Please -cad the filing instructions on the reverse side BEFORE completing this form.
PART I - TO BE COMPLETED BY TRANSFEROR
(Please Type or Print Legibly) O
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TRANSFEROR Name 12O L,
. � USS lL�llU11A 3; SIRUSC I Tor
Address e[orr ,' Num er an tre
fate ,p
TRANSFEREE Name S(/801
Address
Num er an tree[or
sty,Town or P. fate
ip
Address of Property Transferred
um er an tree[or
ny,I own,or
fate Zip
Legal Description of Property 1 V �►� VI ��) n„r�
1• W s(check one)
Mre are no known wells situated on this property.
❑ There is a well or wells situated on this property. The type(s), locations)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
site is deemed to be potentially hazardous. Natural Resources that the
❑ There is a solid waste disposal site on this property which has been deemed to be potentially hazardous by the Department o.h atural
Resources..The location(s)of the site(s)is stated below.
!, 3. Ha ardous 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. Under-ground Storage Tanks(check.one)
There are no known underground storage tanks on this roe p p rty.. (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)below. and any known substance(s)contained are describe,
5. Pfr/ivate Burial Site(check one)
0 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.
iG
Information, if any,required by statements checked above: '
Attachment for Additional Information? Y/N If so,number of pages
I HEREBY DELL THAT THE INFORMATION CONTAINED IN PART I OF THIS STATEMENT IS TRUE AND
_CORgECT
--Signature:—- —— - - -— -- -
y w ,r-
(transrerr..or gent) Telephone,Number:
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PART II-TO BE COMPLETED BY RECORDER -------------- --
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Date of Instrument 8 r Q ® 3 ® 17 4 2 1
Book/I.D. age/I.D. i
Date of Re�®r4.ing q���� City o ownshipontract ❑ Count r
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DNR form(July 99) - - ---------------------
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FILE WITH RECORDER . -----------------
(See Instruction#6) 542-0960