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HomeMy WebLinkAboutA010 - 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 /4</LROX—T ROA-6 OEUEGO^GeS I Z- • C Address •y/ ?j 4 EL L O G C 4V . /d"eT—% rzlz /o Number and Street or RR city,Town or . . State Zip TRANSFEREE Name Aj V 00r+ �.A/IJLJ d l V . 3 rd AtW +(d h Address Number and Street or RR City,Town or P.O. State Zip Address of Property Transferred 300 A-ir/e -*Z"4 7- Ao0-4Z U-4 r-ry /O Number and Street or RR City,Town,or P.O. State p Legal Description of Property /Q-Giil�5 S Timmy C0-yn/ry, S� r I.,Wells(check one) ❑There are no known wells situated on this property. ,,91here 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) 1,Tfiere 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) Affhore is no known hazardous waste on this property. here 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) Wj!'here 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) B"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. �t Information,if any,required by statements ch et'k ed above:el&I- �/�{� .,Q/J � (�0 1-114i 'Ffty.✓o tG�'I fi-t�,i,�,t,�t,, -.- 3—JA a�,�9 a.�. �wv ,�.�,.c �•Y- �'� Attachment r dditional Inform ton? Y/N If so,number of pages I HEREBY D LARE THAT THE INFOR TION CONTAINED IN PART 1 OF THIS STATEMENT IS TRUE AND CORRECT. Signature: �• Telephone Number: (Transferor or Agent --------------------------------------------------------------------------------------------------------------------------------------------------------------------------- PART II-TO BE COMPLETED BY RECORDER 0 5 - p 2 3 3 9 Date of Instrument 4 ©� Book/I.D. Page/I.D. 1 Date of Recording - 0 5 City Jr Township IQMQ-s Deed ❑ Contract ❑ County u DNR form;,lovember 02) FILE WITH RECORDER 542-0960 INSTRUCTIONS FOR COMPLETING GROUNDWATER HAZARD STATEMENT The transferor of real property is required to complete Part I of this form. 3. Hazardous Wastes - "Hazardous waste" is defined in Iowa Code The purpose of the statement is to satisfy legal requirements for filing section 45513.411, 567-141.2 (455B), I.A.C., and federal regulations instruments of conveyance of real property with the county recorder referenced therein. It is generally defined as waste that poses a threat to (Iowa Code Section 558.69). The Department of Natural Resources does human health or the environment. It includes wastes which are not approve or disapprove of property transfers based on these statements. ignitable, corrosive, toxic, explosive, violently reactive, or specifically The statement must be signed by one of the persons transferring the listed as hazardous in the Code of Federal Regulations (40 CFR 261). property interest or that person's agent. An agent signing this form EXCLUDED are household wastes, agricultural wastes returned to the represents the information from transferor to be correct. soil as 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, address,etc.). instructions, triple-rinsed agricultural chemical containers disposed of One statement under each of the numbered items (1, 2, 3, 4 and 5)must by farmers (where the rinsate is used as makeup water in the tankmix be checked, and if one or more of the statements checked requires the acid applied at appropriate rates), and other specific materials. Persons transferor to provide additional information, that information is to be are legally required to be aware of hazardous waste laws. provided in part I. Relate the additional information to the specific category of facility (well, etc.) by numbering it with the corresponding 4. Underground Storage Tanks -"Underground storage tank" means number (1, 2, 3, 4, 5). If additional space is needed, type or print it one or a combination of tanks, including underground piping connected legibly on a separate sheet or sheets,complete the statements at the end of to the tanks, used to contain an accumulation of regulated substances, Part I and attach the additional information to all copies of the form. and the volume of which is 10 percent or more beneath thWurface of When describing the location of a facility on the property, be reasonably the ground. "Regulated substances" include petroleum products and precise,such as a specil'c distance and general direction from a landmark hazardous or toxic materials identified in 567--135.2(455B), I.A.C. or corner of the property. A professional survey is not necessary. The Underground storage tank does not include: following definitions are for use in completing the form. ' a. Farm or residential tanks of 1,100 gallons or less capacity used for 1. Wells - A "well" is any excavation that is drilled, cored, bored, storing motor fuel for noncommercial purposes. But See augered, washed, driven, dug, jetted or otherwise constructed for 455B.473(4)) accessing groundwater or for diverting surface water into the ground, b. Tanks used for storing heating oil for consumptive use on the including abandoned wells. "Well" does not include an open ditch or premises where stored. drainage tiles which discharge to the surface. c. Residential septic tanks. d. Pipeline facilities regulated by state or federal law. If a well is an "abandoned well" or an"agricultural drainage well,"this e. A surface impoundment,pit pond,or lagoon. must be identified and the status of the well with respect to Iowa Code f. A storm water or wastewater collection system. sections 455B.190 and 159.29, respectively, must be stated. An g. A flow-through process tank. "abandoned well" is a well no longer in use or in such state of disrepair h. A liquid trap or associated gathering lines directly related to oil or that continued use is unsafe or impracticable. Abandoned wells are to be gas production and gathering operations. properly plugged in accordance with chapter 39 of the rules of the i. A tank in an underground area such as a basement or mine, if the Department of Natural Resources. (567 Iowa Administrative Code, tank is on or above the surface of the floor. Chapter 39) j. Pipes connected to the above exclusions. An "agricultural drainage well" is a well constructed for the purpose of "Tank type" means the material of construction (steel, fiberglass draining, or which drains, water from agricultural land to an aquifer reinforced plastic[FRP],or other[specify]),and any internal or external (underground),excluding drainage tile intakes which outlet to the surface. protection such as a protective coating or wrapping, or cathodic Agricultural drainage wells are required to be registered with the protection. department by September 30, 1988, and the owner of the well and of the land drained by the well are to develop a plan proposing alternatives to Identify the capacity in gallons and the substance stored in each tank. the use of the well by July 1, 1998(See Iowa Code Section 159.29.) 5. Private Burial Sites - "Private Burial Site" means one or more 2. Solid Waste-"Solid waste"means garbage,refuse,rubbish and other graves containing human remains. For each site the transferor shall state similar discarded solid or semisolid material. It does not include dirt, the location of the site. For each decedent buried on the property the stone,brick,or similar inorganic material used for fill,as long as no other transferor shall state all known identifying information of that decedent solid waste is included. See 567--100.2(455B), Iowa Administrative including name,date of death,and date of birth. Code(I.A.C.)for further definitions. A"disposal site" is any area on the property on,in,or under which solid waste has been disposed,whether or 6. Filing- The original of this form must be presented to the county not the disposal is or was regulated by the department, recorder when the document to be recorded is filed. The Recorder shall forward the original to the transferee when the recorded instrument is If the transferor or agent has not received notice from the Department of returned. The recorder is not required to keep any copies. Natural Resources that the disposal site has been 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 N remediation of underground storage tank releases accomplished in M compliance with Department of Natural Resources rules without a permit C� is not required to be reported as the.disposal of solid waste or hazardous N waste. (See Iowa Code Section 558.69) O LO 0 DNR form(November 02) 543-0960