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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 Bloomington Heights West Townhomes,L.C.
Address 6600 Westown Parkway,Suite 220,West Des Moines,Iowa 50266
Number and sheet a RR City,Tam v P.O. st ee yip
TRANSFEREE Name Bloomington Heights West Townhomes Plat 1 Ames Story County Iowa
Address
Number and Stmd a RR City,Tam v P.O. state Zip
Address of Property Transferred
Numba and sheet or RR City,Tmn Q P.O. state zip
LegalDescriptionofProperty See Exhibit"A".
1.Wells(check one)
® There are no known wells situated on this property.
❑ There is a well orwells situated on this property.The type(s),location(s)and legal status are statedbelow.
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 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 StorAV Tanks(check one)
[XThere are no knownunderground storage tanks on this property.(Note exclusions such as small farm and residential motor fuel tanks,
mostheating oil tanks,cisterns and septic tanks,in instructions.)
❑There is anunderground 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 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:
Attachmentfor Additional Information /N If so,number of pages 1
I HEREB ECLARE T INFORMATION CONTAINED IN PART 1 OF THIS STATEMENT IS TRUE AND CORRECT
Signa Telephone Number:(515)270-1497
arer a
Jo .Gamble./Secretary
- t
PART 11-TO BE COMPLETED BY RECORDER 0 4 — Q 8 [`J 1 6
Date of Instrument 6 1 Z Lf l D N Book/I.D. Page/I.D.
Date of Recording to c ICitvbr Township_ �a
Deed ❑ Contract C3 County
DNR form(July 99) FILE WITH RECORDER 542.0960
(See Instruction#6)
7
EXHIBIT "A"
LEGAL DESCRIPTION
OUTLOT `Z' BLOOMINGTON HEIGHTS WEST PLAT 1, AN OFFICIAL PLAT, CITY OF AMES,
STORY COUNTY, IOWA, AND PARCEL `A' OF THE PLAT OF SURVEY FILED JUNE 17, 2004
AS INSTRUMENT NO. 04-08008, SLIDE 210, PAGE 3, BEING A PART OF OUTLOT `A',
BLOOMINGTON HEIGHTS WEST TOWNHOMES PLAT 1, AN OFFICIAL PLAT, CITY OF
AMES, STORY COUNTY, IOWA
OUTLOT `Z' AND PARCEL `A' CONTAIN 7.436 ACRES MORE OR LESS.