HomeMy WebLinkAboutA013 - Real Estate Transfer - Groundwater Hazard Statement v
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 of Print Legibly)
TRANSFEROR Name Grand Junction, L. C.
Address 6900 Westown Parkway West Des Moines Iowa 50266-2520
Number and Street or RR City,Town or P.O. State Zip
TRANSFEREE Name FAMC, Inc.
Address P. O.Box 1038 Mason City Iowa 50402
Number and Street or RR City,Town or P.O. State Zip
—Address of-Property Transferred 525-Gilchrist Street Ames - Iowa 50010
Number and Street or RR City,Town or P.O. State Zip
Legal Description of Property Lot 2,Grand Junction Subdivision, Second Addition,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)
® 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)
❑ There is no known hazardous waste on this property. .
There is hazardous waste on this propetty and it is being managed in accordance with Department of Natural Resources rules.
4. Underground Storage Tanks(check one)
® 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 substances(s)contained are
described below.
5. Private Burial Site(check one)
® 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 check above: There may be hydrocarbon contamination from leaking underground storage tanks
formerly located on the portion of the Grand Junction Subdivision, Second Addition,formerly described as Parcel"C"in the Southwest Quarter
of the Southwest Quarter of section 2,Township 83 North,Range 24 West of the 5th PM in the City of Ames, Story County,Iowa,as shown on
the Plat of Survey filed for record in the Office of the Recorder for Story County,Iowa on October 13, 1995 in Book 13 of Certificate and Field
Notes,Page 139,which has been identified as LUST No.7LTJ69,Registration No. 8607706. Doolittle Oil Company,Inc.,the former operator
of this gas station remains contractually responsible for any monitoring,reporting and remediation required by the Iowa Department of Natural
Resources.
Attachment.for-Additional Information?Y-/N _ __If so,number of pages
I HEREBY DECLARE THAT THE INFORMATION CONTAINED IN PART I OF THIS STATEMENT IS TRUE AND CORRECT.
Grand Junction, L. C. By: Hubbell Realty Company, Managing Member
Signature: B TLI�/ Date: Telephone Number: (515)280-2051
(Transferor or Agent)R.Michael Hfyes, Secretary
PART H-TO BE COMPLETED BY RECORDER a
I '�d
Date of Instrument 0 I O� Book/I.D. Page/I.D.
Date of Recording Go 1 r 0 ity or Township
Deed Contract ❑ County 6A Vj
DNR form(July 99) FILE WITH RECORDER e42-0960
(See Instruction#6)
0 - 11729
INSTRUCTIONS FOR COMPLETING GROUNDWATER HAZARD STATEMENT
The transferor of real property is required to complete Part I of this 3. Hazardous Wastes - "Hazardous waste" is defined in Iowa
form. The purpose of the statement is to satisfy legal requirements Code section 455B.411, 567--141.2 (455B), I.A.C., and federal
for filing instruments of conveyance of real property with the regulations referenced therein. It is generally defined as waste that
county recorder (Iowa Code Section 558.69). The Department of poses a threat to human health or the environment. It includes
Natural Resources does not approve or disapprove of property wastes which are ignitable, corrosive, toxic, explosive, violently
transfers based on these statements. The statement must be signed reactive, or specifically listed as hazardous in the Code of Federal
by one of the persons transferring the property interest or that Regulations (40 CFR 261). EXCLUDED are household wastes,
person's agent. An agent signing this form represents the agricultural wastes returned to the soil as fertilizers or soil
information from transferor to be correct. conditions, agricultural chemicals applied or disposed.of by a
farmer in accordance with the manufacturer's instructions, triple-
For the most part the information requested is clear(name,address, rinsed agricultural chemical containers disposed of by farmers
etc.). One statement under each of the numbered items (1, 2, 3, 4 (where the rinsate is used as makeup water in the tankmix and
and 5) must be checked, and if one or more of the statements applied at appropriate rates), and other specific materials. Persons
checked requires the transferor to provide additional information, are legally required to be aware of hazardous waste laws.
that information is to be provided in Part I. Relate the additional
—information-to the specific-=category of facility (well,--etc;) -by-_ - 4.- -Underground-Storage-Tanks - "Underground-storage-tank'
numbering it with the corresponding number (1, 2, 3, 4, 5). If means one or a combination of tanks, including underground
additional space.is needed, type or print it legibly on a separate piping connected to the tanks, used to contain an accumulation of
sheet or sheets, complete the statements at the end of Part I and regulated substances, and the volume of which is 10 percent or
attach the additional information to all copies of the form. When more beneath the surface of the ground. "Regulated substances"
describing the location of a facility on the property, be reasonably include petroleum products and hazardous or toxic materials .
precise, such as a specific distance and general direction from a identified in 567--135.2(455B), I.A.C. Underground storage tank
landmark or corner of the property. A professional survey is not does not include:
necessary. The following definitions are for use in completing the
form. a. Farm or residential tanks of 1,100 gallons or less capacity used
for storing motor fuel for noncommercial purposes. (But See
1. Wells-A"well"is any excavation that is drilled, cored,bored, 455B.473(4))
augured, washed, driven, dug, jetted or otherwise constructed for b. Tanks used for storing heating oil for consumptive use on the
accessing groundwater or for diverting surface water into the premises where stored.
ground, including abandoned wells. "Well" does not include an c. Residential septic tanks.
open ditch or drainage tiles which discharge to the surface. d. Pipeline facilities regulated by state or federal law.
e. A surface impoundment,pit pond,or lagoon.
If a well is an"abandoned well"or an"agricultural drainage well," f. A storm water or wastewater collection system.
this must be identified and the status of the well with respect to g. A flow-through process tank.
Iowa Code sections 455B.190 and 159.29, respectively, must be h. A liquid trap or associated gathering lines directly related to
stated. AA"abandoned well" is a well no longer in use or in such oil or gas production and gathering operations. '
state of disrepair=that continued_use is-unsafe-or impracticable._ A_tank in_an underground area such as a basement or mine, if
Abandoned wells are to be properly plugged in accordance with the tank is on or above the surface of the floor.
chapter 39 of the rules of the Department of Natural Resources. j. Pipes connected to the above exclusions.` '
(567 Iowa Administrative Code,Chapter 39)
"Tank type" means the material of construction (steel, fiberglass
An "agricultural drainage well" is a well constructed for the reinforced plastic [FRP], or other [specify]), and any internal or
purpose of draining, or which drains, water from agricultural land external protection such as a protective coating or wrapping, or
to an aquifer(underground), excluding drainage tile intakes which cathodic protection.
outlet to the surface. Agricultural drainage wells are required to
be registered with the department by September 30, 1988, and the Identify the capacity in gallons and the substance stored in each
owner of the well and of the land.drained by the well are to develop tank.
a plan proposing alternatives to the use of the well by July 1, 1998.
(See 1991 Iowa Code Section 159.29.) 5. Private Burial Sites - "Private Burial Site" means one or
more graves containing human remains. For each site the
2. Solid Waste - "Solid waste" means garbage, refuse, rubbish transferor shall state the location of the site. For each decedent
and other similar discarded solid or semisolid material. It does not buried on the property the transferor shall state all known
include dirt, stone,brick, or similar inorganic material used for fill, identifying information of that decedent including name, date of
as long as no other solid waste is included. See 567-100.2(455B), death,and date of birth.
Iowa Administrative Code (I.A.C.) for further definitions. A
"disposal site" is any area on the property on, in, or under which 6. Filing - The original of this form must be presented to the
solid waste has been disposed,whether or not the disposal is or was county recorder when the document to be recorded is filed. The
regulated by the department. Recorder shall forward the original to the transferee when the
recorded instrument is returned The recorder is not required to
If the transferor or agent has not received notice from the keep any copies.
Department of Natural Resources that the disposal site has been
deemed to be potentially hazardous, there is no duty to inquire to
the department.
*Note The land application of sludges or soils resulting from the
remediation of underground storage tank releases accomplished in
compliance with Department of Natural Resources rules without a
permit is not required to be reported as the disposal of solid waste
or hazardous waste. (See Iowa Code Section 558.69)
DNR form(July 99) 543-0960