HomeMy WebLinkAboutA009 - Real Estate Transfer - Groundwater Hazard Statement . REAL ESTATE TRANSFER -GROUNDWATERHAZARDSTATEMENT
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 R.Friedrich&Sons,Inc.,et al.
Address 6th&Duff,Ames,IA 50010
Number and Street or RR
City,Town or P.O. State Zip
TRANSFEREE Name Somerset Subdivision Nineteenth Addition
Address State Zip
Number and Street or RR City,Town or P.O.
Address of Property Transferred
Number and Street or RR City,Town,or P.O. State ZAP
Legal Description of Property See attached Addendum.
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)of the sites)is statedbelow.
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 Storage Tanks (check one)
'^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)
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?YG If so,number of pages
I`HEREBY DY 7CLARE THAT T,,IHE INF RMATION CONTAINED.IN PART 1 OF THIS STATEMENT IS TRUE AND CORRECT
Telephone Number:(515)233-4450
Signature: r
(Transferor o'
u PART 11 - TO BE COMPLETED BY RECORDER
Date of Instrument �L 7 Book/I.D. Page/I.DO 4 — 1 5 ® 9 7
Date of Recording �, 1 City ownship i
PkA+
Deed ❑ Contract 0 County
--------_•--------------------------------------
DNR form(July 99) FILE WITH RECORDER 542-0960
(See Instruction#6)
INSTRUCTIONS FOR COMPLETING GROUNDWATER HAZARD STATEMENT
The transferor of real property is required to complete Part I•of this 3.Hazardous Wastes- "Hazardous waste" is defined in Iowa
form.The purpose of the statement is to satisfy legal requirements Code section 455B.411, 567--141.2 (455B), I.A.C., and federal
for filing instruments of conveyance of real property with the regulations referenced therein. It is generally defined as waste
county recorder (Iowa Code Section 558.69). The Department of that poses a threat to human health or the environment. It
Natural Resources does not approve or disapprove of property includes wastes which are ignitable, corrosive, toxic, explosive,
transfers based on these statements.The statement must be signed violently reactive,or specifically listed as hazardous in the Code
by one of the persons transferring the property interest or that of Federal Regulations (40 CFR 261). EXCLUDED are
person's agent. An agent signing this form represents the household wastes,agricultural wastes returned to the soil as
information from transferor to be correct. fertilizers or soil conditioners, agricultural chemicals applied or
disposed of by a farmer in accordance with the manufacturer's
For the most part the information requested is clear(name, instructions, triple-rinsed agricultural chemical containers
address, etc.). One statement under each of the numbered items disposed of by farmers(where the rinsate is used as makeup
(1, 2,3,4 and 5) must be checked, and if one or more of the water in the tankmix and applied at appropriate rates), and other
statements checked requires the transferor to provide additional specific materials. Persons are legally required to be aware of
information,that information is to be provided in part I.Relate the hazardous waste laws.
additional information to the specific category of facility (well,
etc.) bya numbering it with the corresponding number (1, 2, 3, 4, 4.Underground Storage Tanks - "Underground storage tank"
5).If additional space is rieeded,`type or print it legibly on a � -- -
separatesheet or sheets,complete the statements at the end of Part means one or a combination of tanks,including underground
I and attach the additional information to all copies of the form. piping connected to the tanks,used to contain an accumulation of
When describing the location of a facility on the property,be regulated substances, and the volume of which is 10 percent or
reasonably precise, such as a specific distance and general more beneath the surface of the ground. Regulated substances"
direction from a landmark or corner of the property.A include petroleum products andhazardous or toxic materials
professional survey is not necessary.The following definitions are identified in 567--135.2(455B),I.A.C.Underground storage
for use in completing the form. tank does not include:
a.Farm or residential tanks of 1,100 gallons or less capacity
1. Wells -A"well"is any excavation that is drilled,cored,bored, used for storing motor fuel for noncommercial purposes. But
augered, washed, driven, dug,jetted or otherwise constructed for See 455B.473(4)
accessing groundwater or for diverting surface water into the b. Tanks used for storing heating oil for consumptive use on the
ground, including abandoned wells. "Well" does not include an premises where stored.
open ditch or drainage tiles which discharge to the surface. c.Residential septic tanks.
If a well is an"abandoned well"or an "agricultural drainage well," d.Pipeline facilities regulated by state or federal law.
this must be identified and the status of the well with respect to e.A surface impoundment,pit pond,or lagoon.
f.A storm water or wastewater collection system.Iowa Code sections 455B.190 and 159.29, respectively, must be
stated. An "abandoned well"is a well no longer in use or in such Aflow-through process tank.
state of disrepair that continued use is unsafe or impracticable. �• A liquid trap or�associated gathering lines directly related to
oil or gas production and gathering operations.
Abandoned wells are to be properly plugged in accordance with
chapter 39 of the rules of the-Depat�tment of Natural Resources, i. A tank in an underground area such as a basement or mine, if
(567 Iowa Administrative Code,Chapter 39) the tank is on or above the surface of the floor. -
j. Pipes connected to the above exclusions.
An"agricultural drainage well"is a well constructed for the "Tank type"means the material of construction,(steel,fiberglass
purpose of draining,or which drains,water from agricultural land reinforced plastic [FRP], or other[specify]), and any internal or
to an aquifer(underground),excluding drainage tile intakes which external protection such as a protective coating or wrapping, or
outlet to the surface. Agricultural drainage wells are required to cathodic protection.
be registered with the department by September 30, 1988,and the
owner of the well and of the land drained by the well are to Identify the capacity in gallons and the substance stored in each
develop a plan proposing alternatives to the use of the well by tank.
July 1, 1998(See Iowa Code Section 159.29.)
5.Private Burial Sites- "Private Burial Site"means one or
2. Solid Waste- "Solid waste"means garbage, refuse,rubbish more graves containing human remains. For each site the
and other similar discarded solid or semisolid material.It does not transferor shall state the location of the site. For each decedent
include dirt,stone,brick,or similar inorganic material used for fill, buried on the property the transferor shall state all known
as long as no other solid waste is included.See 567--100.2(455B), identifying information of that decedent including name,date of
Iowa Administrative Code(I.A.C.)for further definitions.A death,and date of birth.
"disposal site" is any area on the property on, in, or under which
solid waste has been disposed, whether or not the disposal is or 6.Filing-The original of this form must be presented to the
was regulated by the department. county recorder when the document to be recorded is filed. The
Recorder shall forward the original to the transferee when the
If the transferor or agent has not received notice from the recorded instrument is returned. The recorder is not required to
Department of Natural Resources that the disposal site has been keep any copies.
deemed to be potentially hazardous, there is no duty to inquire to
the department. - -- - - --- - ---- — -
*Note The land application of sludges or soils resulting from the
remediation of underground storage tank releases accomplished in
compliance 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)
DNR form(July 99) u
543-0960
ADDENDUM:
THE PLAT OF SOMERSET SUBDIVISION NINETEENTH ADDITION
BEING AN OFFICIAL REPLAT OF LOTS 25, 26, 27, 28 AND
PARCEL "E" OF OUTLOT RR AS SHOWN ON THE "PLAT OF
SURVEY" FILED IN THE OFFICE OF THE RECORDER OF STORY
COUNTY, IOWA, ON OCTOBER 25, 2004) AS INSTRUMENT
NUMBER 04-00014427, IN SLIDE 224 AT PAGE 1, ALL IN
SOMERSET SUBDIVISION THIRD ADDITION, AN OFFICIAL PLAT,
AMES, STORY COUNTY, IOWA IS DESCRIBED AS FOLLOWS:
BEGINNING AT THE NORTHWEST CORNER OF LOT 25 IN SAID
SOMERSET SUBDIVISION THIRD ADDITION; THENCE
S7401 P00"E-(PLATTED BEARING) ALONG THE NORTHERLY LINE
OF SAID LOT 25, A DISTANCE OF 95.07 FEET TO THE
NORTHEAST CORNER OF SAID LOT 25; THENCE
SOUTHEASTERLY ALONG THE EASTERLY LINE OF LOT 25 AND
ALONG THE NORTHERLY LINE OF LOTS 26, 27 AND 28 IN SAID
SOMERSET SUBDIVISION THIRD ADDITION AND ALONG A 55.00
FEET RADIUS CURVE CONCAVE NORTHEASTERLY, A
DISTANCE OF 161.10 FEET, SAID CURVE HAVING A CHORD
BEARING OF S65029'06"E AND A CHORD LENGTH OF 109.38
FEET; THENCE N90°00'00"E ALONG THE NORTHERLY LINE OF
SAID LOT 28, A DISTANCE OF 11.81 FEET TO THE NORTHEAST
CORNER OF SAID LOT 28; THENCE S03°00'37"W ALONG THE
EASTERLY LINE OF SAID LOT 28, A DISTANCE OF 118.49 FEET
TO THE SOUTHEAST CORNER OF SAID LOT 28 AND TO THE
NORTHEAST CORNER OF PARCEL "E" OF OtTLOT RR IN SAID
'SOMERSET SUBDIVISION THIRD 4 ADDITION; THENCE
S28008'37"W ALONG THE EASTERLY LINE OF SAID PARCEL "E",
A DISTANCE OF 13.00 FEET; THENCE N84002'25"W ALONG THE
SOUTHERLY LINE OF SAID PARCEL "E", A DISTANCE OF 43.29
FEET; THENCE N72°30'00"W ALONG THE SOUTHERLY LINE OF
SAID PARCEL "E", A DISTANCE OF 87.77 FEET; THENCE' '
N56024'13"W ALONG THE SOUTHERLY LINE OF SAID PARCEL
"E", A DISTANCE OF 47.32 FEET; THENCE N18°06'27"W ALONG
THE WESTERLY LINE OF SAID PARCEL "E", A DISTANCE OF
50.30 FEET; THENCE N05°08'00"W ALONG THE WESTERLY LINE
OF SAID PARCEL "E", A DISTANCE OF 96.59 FEET TO THE POINT
OF BEGINNING.