HomeMy WebLinkAboutA010 - Real Estate Transfer - Groundwater Hazard Statement REAL ESTATE TRANSFER -GROUNDWATERHAZARD 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 Scott E.Randall
Address 420 S. 17th Street,Ames,IA 50010
Number and Street or RR City,Town or P.O. State Zip
TRANSFEREE Name City of Ames
Address 515 Clark Avenue,Ames,IA 50010
Number and Street or RR City,Town or P.O. State Zip
Address of Property Transferred 405 16th Street, 615 16th Street,and 917 16th Street,Ames,IA
Number and Street or RR City,Town,or P.O. State Zip
Legal DescriptionofProperty Grand Aspen Subdivision,Second Addition to the City of Ames,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)ofthe site(s)is stated below.
3.Hazardous Wastes(check one)
There i S no knov.,n hazardous waste on th i cP-r�Pn erty
❑ 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 ones
There are no known underground storAg6 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)
There are no known private burial sites on this property.
❑ There is aprivate 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 checked above:
Attachment for Additional Information?Y/0 If so,number of pages
I HEREBY DECLARE TH INFORMATIO CONTAINE T n ADT '—OF THIS STATEMENT IS TRUE AND CORRECT
Signature: Telephone Number:
(Transferor or Agent)
.., ( PART 11 - TO BE COMPLETED BY RECOADAR
Date of Instrument_ 25414
I �l7So�c'� Book/I.D. Page/I.D.
Date of Recording ?.to(-to( C'ty Township �r.Q�
lLt
Deed ❑ Contract ❑ County 4E-
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DNR form (July 99) FILE WITH RECORDER
542-0960
(See Instruction#6)