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HomeMy WebLinkAboutA008 - Real Estate Transfer - Groundwater Hazard Statement s ; 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 �� Address 114Z( S �e�� Ave "►� )y\ ryw\eS �TA Number ana street or RR City,G[y iown or P.U. Late Zip TRANSFEREE Name Address Num er an tree[or _ ' ity,Town or P. fate Lip Address of Property Transferred . um er an treet or RR ity,Town,or P. - - Legal Description of Property �,.o�.s 'Z.�� Z $ �© a m tr 1. ells(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) AThere is no known solid waste disposal site on this property. 13"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) �Q 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) 1&here are no known underground storage tanks on this roe t p p ns. (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 describe 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 checked above: Attachment for Additional Information? Y/0 If-so;number of pages I HEREBY DECLARE THAT THE INF 1MATION CONTAINED IN PART 1 OF THIS STATEMENT IS TRUE AND CORRECT Signature: (Trans eror or ,enq -Telephone Number: a3a^aV ----------------- _____ PART H-TO BE COMPLETED BY RECORDER Date of Instrument p 0 ll Zl Book/I.D. Page/I.D. Date of Recording tl Z p�� ity ownship Deed ❑ Contract ❑ County S ------------------------------------------------ - DNR form(July 99) - --------- FI-LE-- -W-I- ---------------------------------------------------------- TH- - RECORDER --------- (See Instruction#6) 542-0960 INSTRUCTIONS FOR UUivu'>_L t rlvv d U il9 3. Hazardous Wastes - "Hazardous s is t e rn a The transferor of real property is required to complete Part I of this Code section 455B.411, 567=-141.2 (455B), LA.C., and federal foram. The purpose of the statement is to satisfy legal requirements generallydefined as waste for filing instruments of conveyance of real property with the lhgt lalooes a threatns letotlhuman health or the environment. li county recorder.(Iowa Code Section 558.69). The Department of includes was which are igtnitablc, corrosive, toxic, explosive. Natural Resources does not approve or disapprove of property violently reactive, or;specifically listed as hazardous in the Codc transfers based on these statements.'The statement must be signed Y the persons transferring the properly interest or thaC"'"' of Federal wastes, s6returnedXtL 1DBDtlaa- by one'of p b . _ 1,. person.'s agent. An agent signing this form represents the Teri lizerlsor soil co11 ltioncis; gricultural chetmcals applied o. informatioii.from transferor to be correct. disposed of by a fanner'in.accordance with the manufacturer', most art the inforntatioil requested is clear (name, instructions, triple-rinsed agricultural chemical „container. For then p dis osed -of by farmers (where the rinsate is used as aocul the address, etc.). One statement under each of tine numbered items P. 1 2 3, 4 and 5) must-be checked, and if one or more of tile specific l ►naleria6r in the t is tt Persons arcdlegal y r at qui�red tte o be aware o statements checked requires the transferor to provide additional information,that information is to be provided in part I. Relate tine hazardous waste laws. additional information to tile. specific calcgory,of facility (well, b numbering it with the corresponding number (1, 2, 3, 4, 4. Uri"dergrou»d Storage Tanks - "Underground storage lack etc.) y means one or a combination of tanks, including undergroun, additional space_is needed, ype or print it legibly on a sheeCor sheets, complete the statements at the end of fart` -piping-coiztt�ctcd!o_llne_tanlcs, used to contain an accumulation a separateregulated substances, and,llic volume of which is 10 percent c more�beneatln the surface of the ground. "Regulated substances I.and attach, the.additional information ,to all copies oC the for"'- When describing the location of a faci]ity oin 'the property, be ' include petroleum products and hazardous, or toxic maleria. reasonably precise, sucli as a speciC�c distance �and general p. m a landmark or corner oC the `property. ' A•� ' 'identiGed� in 567--135.2(4'SSB),-'I:A•.0 Uiiderground-'storag . direction from tank does not include: professional survey is not necessary. The following definitions arc gallons or less capaci' for use in completing the form. a. Farm or residential tanks of 1,100 b "well" is any excavation that is drilled,cored,bored, used for storing motor fuel for noncommercial purposes. B augereds washed, drivern, dug,jetted or otherwise constructed for 1. See 455B.473(4)) groundwater .or for diverting surface water into the b. Tanks used for storing;treating oil for consumptive use out tl accessing gro remises 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 e. A surface impoundment,pit pond, or lagoon. IBC a well is all"abandoned well"or an"agricultural drainage well," f A storm water or wastewater collection system:this must be identified and the status of rite well with respect to A now-through process tank. ' lt. A liquid trap or associated gathering litres directly related � Iowa Code sections 455II.190 and 159.29, respectively, must be g• stated. An"abandoned well" is a well no longer in use or in such oil or as roductiou and gathering operations. i. A tank in an underground area such as a basement or mine state of disrepair that continued use is unsafe or impracticable. g Abandoned wells arc to be properly plugged in accordance with lire tank is out or above tine surface of the Moor. chapter 39 of the rates-of-tine=Dcpartzncnt-of Nat»ral_IZcs�urces. �: l;pcs coniiected-1 the'abovc exclusions. - -- - - .(567 Iowa Administrative Code,Chapter 39). ^ ultural drainage well" is, a' well constructed for the "Tank type" means the material of construction (steel, nterfibe gl An ,.agrrc or other:[specify]), and any internal purpose of drainiilg,'or which drains, water from agricultural land reinforced plastic [FRP], uifer• under round),excluding drainage rile intakes which external protectiotn suclt''as a protective coating or wrapping. is to an aq ( g 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 e owner of the well and of the land drained by the well are to tank. develop a plan proposing alternatives to the use of the well by July 1, 1998 (See Iowa Code Section 159.29.) 5, Private Burial Sites - "Private Burial Site" means on( more graves human Solid Waste - "Solid waste" inieans garbage, refuse, rubbish transferor shall state'tile location of remains. For each decei 2. S _ and other si►nilar discarded solid or semisolid material. It does not buried on the property the transferor shall state all ktn include dirt,stone, brick,or similar inorganic material used for fill, identifying information'of that decedent including name, dat as long as no other solid waste is included. See 567--100.2(455B), deatlij and date of birth. Iowa.Administrative Code (I.A.C.) for further definitions. A "disposal site" is any area on tine properly on, ini.or under which 6. Filin The original of this form'must be presented to solid waste has been disposed, whether or riot the disposal is or county recorder when the document to be recorded is filed. was regulated by tine.deTartment. Recorder shall forward'.the or to the transferee when transferor 'or agent has not received notice from the recorded copies. is returned. The recorder is not require If the trans[ g keep an Department of Natural pResources that die disposal site has-been y P Y p.., deemed,to be polentialiy hazardous, there is no.duty to inyire.to th_e department. *Note The land application of sludges or soils resulting from the remcdiation of underground storage tank releases accomplished in compliarnce.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) s DNR form,(July.99)'