The URL can be used to link to this page

Home My WebLink AboutA014 - Real Estate Transfer - Groundwater Hazard Statement REAL ESTATE TRANSFER-GROUNDWATER HAZARD STATEMENT TRANSFEROR: TO BE COMPLETED BY TRANSFEROR Name Kellie M. Markie Revocable Trust Address 5185 Waterfront Court Pleasant Hill IA 50327 Number and Street or RR City,Town or P.O. State zip TRANSFEREE: Name_City of Ames, Iowa Address 515 Clark Avenue Ames IA 50010 NU11WeF cWU 01reVLor KM Uity,Tmm or a e p Address of Property Transferred: 707 Airport Road,Ames, Iowa — Number and Street or RR Zity,I own.or P75. state Legal Description of Property: (Attach if necessary) Lots A and B.of Airport Business Park, an Official Plat now included in and forming a part of the City of Ames, Story Uounty,Iowa 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 or set forth on an attached separate sheet, as necessary. 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 and information related thereto is provided in Attachment#1, attached to this document. 3. Hazardous Wastes (check one) El There is no known hazardous waste on this property. ❑ There is hazardous waste on this property and information related thereto is provided in Attachment 01, attached to this document. 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 on this property. The type(s), size(s) and any known substance(s) contained are listed below or on an attached separate sheet, as necessary. FILE WITH RECORDER DNR form 642-0960(June 26,2009) f i 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)and known identifying information of the decedent(s) is stated below or on an attached separate sheet, as necessary. 6. Private Sewage Disposal System (check one) ® There are no known private sewage disposal systems on this property. ❑ There is a private sewage disposal system on this property. A certified inspector's report is attached which documents the condition of the private sewage disposal system and whether any modifications are required to conform to standards adopted by the Department of Natural Resources. A certified inspection report must be accompanied by this form when recording. ❑ There is a private sewage disposal system on this property. Weather.or other temporary physical conditions prevent the certified inspection of the private sewage disposal system from being conducted. The buyer has executed a binding acknowledgment with the county board of health to conduct a certified inspection of the private sewage disposal system at the earliest practicable time and to be responsible for any required modifications to the private sewage disposal system as identified by the certified inspection. A copy of the binding acknowledgment is attached to this form. When the inspection is completed an amended Groundwater Hazard Statement shall be recorded with the certified inspection and shall include the document numbers of both the real estate transfer document and the original Groundwater Hazard Statement. ❑ There is a private sewage disposal system on this property. The building to which the sewage disposal system is connected will be demolished without being occupied. The buyer has executed a binding acknowledgment with the county board of health to demolish the building within an agreed upon time period. A copy of the binding acknowledgment is provided with this form. ❑ This property is exempt from the private sewage disposal inspection requirements pursuant to the following exemption: ❑ The private sewage disposal system has been installed within the past two years pursuant to permit number Information required by statements checked above should be provided here or on separate sheets attached hereto: I HEREBY DECLARE THAT I HAVE REVIEWED THE INSTRUCTIONS FOR THIS FORM AND THAT THE INFORMATION STATED ABOVE IS TRUE AND CORRECT. Signature: C 0 9 Telephone No.S�J `3 655Bo (rransferor or gent FILE WITH RECORDER DNR form 642.0960(June 26,2009) GROUNDWATER HAZARD STATEMENT ATTACHMENT#1 NOTICE OF WASTE DISPOSAL SITE a. Solid Waste Disposal (check one) ❑ 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 or on an attached separate sheet, as necessary. b.. Hazardous Wastes(check one) b There is hazardous waste on this property and it is being managed in accordance with Department of Natural Resources rules. ❑ There is hazardous waste on this property and the appropriate response or remediation actions, or the need therefore, have not yet been determined. Further descriptive information: I HEREBY DECLARE THAT I HAVE REVIEWED THE INSTRUCTIONS FOR THIS FORM AND THAT THE INFORMATION STATED ABOVE 1S TRUE AND CORRECT. Signature: Telephone No.: S/53O6 6-500 CrraMferor or ern FILE WITH RECORDER DNR form 642-0960—Attachment 91 (June 26,2009)