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HomeMy WebLinkAboutA022 - 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 Southfork Development,L.L. C. Address 200 Stanton Ave.,Ames,IA 50014 Number and Street or RR City,Town or P.O. State Zip TRANSFEREE Name City of Ames,Iowa Address 515 Clark Ave.,Ames,IA 50010 . Number and Street or RR City,Town or P.O. State Zip Address-of Prep.erty_Transferred South Fork Subdivision, Second Addition,Ames,Iowa Number and Street or RR City,Town,or P.O. w — State— Zip Legal Description ofProperty The plat of South Fork Subdivision,Second Addition,which is Outlot"Q"of Plat 1, South Fork Subdivision,an Official Plat of Ames, Story County,Iowa,in the Southeast Quarter of the Northwest Quarter and the Northeast Quarter of the Northwest Quarter of SEction 8,Township 83 North,Range 24 West of the 5th P.M.,in the City of 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)ofthe site(s)is stated below. 3.Hazardous Wastes (check one) here is ro kp_owli hazardous.waste on th i s property ❑ There is hazardous waste on this property and it is being managed in accordance with Department of Natural Resources rules. 4.Undefground Storage Tanks(check one) ' p 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) N-.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 If so,number of pages I HEREBY DEC THA THE INFORM ION CONTAINED IN PART 1 OF THIS STATEMENT IS TRUE AND CORRECT Signature r - � Z�2— Telephone Number: �C Ll 32, (Transferor Agen) PART 11 - TO BE COMPLETED BY RECORDER Date of.Instrument U� � �o� 04 - 0 2 1 9 Book/I.D. Page/I.D. Date of Recording r© City or ownship W 1. DeedX Pit$dn rA County --- --------------------------- DNR form (July 99) FILE WITH RECORDER 1 542-0960 (See Instruction#6)