HomeMy WebLinkAboutA003 - Grandwater Hazard Statement, Instrument No. 2020-10534, Instrument No. GWH2020-01319 Instrument N: GWH2O20-01319
09/10/2020 02:59:59 PM Total Pages: 3
GWH GROUND WATER HAZARD
Stacie Herridge, Recorder, Story County Iowa
GWH Related ID: 2020-10534
WD WARRANTY DEED
09/10/2020 02:59:59 PM
Stacie Herridge, Recorder, Story County Iowa
REAL ESTATE TRANSFER- GROUNDWATER HAZARD STATEMENT
TO BE COMPLETED BY TRANSFEROR
TRANSFEROR:
Name Fareway Stores, Inc.
Address 715 8tn Street;Boone,IA 50036
Number and Street or RR City,Town or P.O. State j
Zip
TRANSFEREE:
Name Burgie's Land Co., LLC
Address 3314 Cedar Lane, Ames, IA 50014
Number and Street or RR City,Town or P.O. State
Zip
Address of Property Transferred:
3701 Stange Road, Ames,IA 50010
Number and Street or RR City,Town or P.O. State Zip
Legal Description of Property: Lot Two (2), Northridge Heights Subdivision Nineteenth
Addition, Ames, Story County, 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)
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.
FILE WITH RECORDER DNR form 542-0960(July 18,2012)
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.
5. Private Burial Site(check one)
There are no known private burial sites on this properly.
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)
.All 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#9]
—This property is exempt from the private sewage disposal inspection requirements
pursuant to the following exemption [Note: for exemption#9 use prior check box]:
The private sewage disposal system has been installed within the past two years pursuant
to permit number
FILE WITH RECORDER DNR form 542-0960 (July 18, 2012)
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.
l
Signature: Telephone No.: (515)432-2623_
Reynol s W. Cramer, President& CEO
Fareway Stores,Inc.
1
FILE WITH RECORDER DNR form 542-0960 (July 18, 2012)