HomeMy WebLinkAboutA015 - Real Estate Transfer - Groundwater Hazard Statement 1/ Iastrtt�tt:2013-00001W4
ut �Ft Date:Oct 07r2013 10:45:42A
d- D Rec Fee: .00 E-Cat Fee: 00
G� Aud Fee: .00 Trans Tax: 00
�F( Rec hanasesent Fee: .00
Non-Standard Page Fee: .00
Filed for record in Storg Counter €ovu
Susan L. Vande Kawt CotxtUt Recorder
REAL ESTATE TRANSFER-GROUNDWATER HAZARD STATEMENT
TO BE COMPLETED BY TRANSFEROR
TRANSFEROR:
Name
Address f�bC(I Vt1 btP F�l i >'L^iES �ff 1vQ 5b y l y
tlumtier and treet qr RR City,Town qr PO state Zip
TRANSFEREE:
Name Rw-di 4
Address (Odicl 1 Prairi-C' VIVIC13 Pr afYoda (f) i 'tmayj
Number and Street or RR City,Town or PO State Zip
Address of Property Transferred:
NA
Number and Street or RR City,Town or PO State Ztp
Legal Description of Property:(Attach if necessary)
j� 3Ol' f
1 rh W
1. Well,�-(check one)
here 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)
{'There is no known hazardous waste on this property.
❑ There is hazardous waste on this property and information related thereto is provided in Attachment#1,
attached to this document
4. UndJrground 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 ONR Form 542-0960 luty 18�2012 cmz
S. Privsite Burial Site(check one)
,E 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.
&. Private Sewage Disposal System(check one)
Rll buildings on this property are served by a public or semi-public sewage disposal system-
This transaction does not involve the transfer of any building which has or is required by law to have a
sewage disposal system.
❑There is a building served by private sewage disposal system on this property or a building without any
lawful sewage disposal system.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 building served by 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.
❑There is a building served by private sewage disposal system on this property.The buyer has executed a
binding acknowledgment with the county board of health to install a new private sewage disposal system
on this property within an agreed upon time period.A copy of the binding acknowledgment is provided with
this form.
❑There is a building served by 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-[Exemption#91
❑This property is exempt from the private sewage disposal inspection requirements pursuant to the following
Exemption[Note:for exemption#9 use prior check boxi:
❑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 VE REVIEWED THE INSTRUCTIONS FOR THIS FORM
AND THAT TMIfNFO M 7ION STATED ABOVE IS TRUE AND CORRECT.
Signature: Telephone No.:
(rran eror rA ent)
FILE WITH RECORDER MR Form 542-0960 July 18'"20I2 Cm