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HomeMy WebLinkAboutA008 - Groundwater Hazard Statement ' r , REAL ESTATE TRANSFER - GROUNDWATER HAZARD STATEMENT Please read the filing instructions on the reverse side BEFORE completing this form. PART I�-pTO BE COMPLETED BY TRANSFEROR TRANSFEROR Name C 7 l: C p& 1 -T►f`- q,�� Address � �]�91 a © Lp N"`n) Number an Veet or KK n City,lownorF.U. st ate zip- TRANSFEREE Name L-1 AV S1�.b�i o IS' 1 Address Number and Street or RR City,Town or P.O. tale Zip Address of Property Transferred Number and Street or RR City,Town,or P.O. Stale Zip Legal Description of Property 1. Wells(check one) There are no known wells situated on this property. I 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. I-I 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. H ardous 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 Storage Tanks(check one) l� 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. Vvate Burial Site(check one) There are no known private burial sites on this property. I I 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/N If so,number of pages I HEREBY DECLARE T T THE INFORM T CONTAINED IN PART 1 OF THIS STATEMENT IS TRUE AND CORRECT. Signature: Q Telephone Number: _a5) cg3a�'401 (Transferor or n ------------------------------------- --------------------- �/ PART II-TO BE COMPLETED BY RECORDER ^ A 414 - Date of Instrument lfl,ySl U/ Book/I.D. Page/I.D. I) r 099 Date of Recording O \ 0 ity Township prole5 Deed I I Contract J County --------------------------------------------------------------------------------------------------------------- DNR form(November 02) FILE WITH RECORDER 542-0960