HomeMy WebLinkAboutA011 - Real Estate Transfer - Groundwater Hazard Statement 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
TRANSFEROR Name WdRGVERITE SEVIDE ET-AL
Address 1(0,) sou-I (t••t
Number an tree[or 1uuy,Town or P.O.
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TRANSFEREE Name R
Address
um er an tree[or rty, own or
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Address of Property Transferred I V'r'I
UMber and St,ee1[or p City,Town,or tate Z1P
Legal Description of Property �1V(/, �[N 01J IVES7
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I. Wells(check one)
7( There Pre 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)
X 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)
-;K 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)
X 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 on this property. The type(s),size(s)and any known substance(s)contained are described below.
5. Private Burial Site(check one)
X 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 forAdditional Information? Y/N If so,number of pages
I HEREBY DECLARE THAT THE INFORMATION CONTAINED IN PART 1 OF THIS STATEMENT IS TRUE AND CORRECT.
Signature: �q?�
(T nsr or o sent[ Telephone Number: _(���/a'D?Jr[J/
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PART II-TO BE COMPLETED BY RECORDER n A 4 7
Date of Instrument�,�I d Book/I.D. Page/I.17 6$ 1
Date of Recording L tt��
ilts) ay C t� Township 1 -A
Deed Contract - �County J
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DNR form(November 02) FILE WITH RECORDER 542-0960