REAL ESTATE TRANSFER - GROUNDWATER HAZARD STATEMENT TO BE COMPLETED BY TRANSFEROR TRANSFEROR Name___________________________________________________________________________________________________________ Address _________________________________________________________________________________________________________ Number and Street or RR City, Town or P.O. State Zip TRANSFEREE Name____________________________________________________________________________________________________________ Address __________________________________________________________________________________________________________ Number and Street or RR City, Town or P.O. State Zip Address of Property Transferred _______________________________________________________________________________________ Number and Street or RR City, Town, or P.O. State Zip Legal Description of Property _________________________________________________________________________________________ 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 site(s) is stated below. 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 on this property. The type(s), size(s) and any known substance(s) contained are listed 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 shall be provided on a separate sheet 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: _____________________________________________________________ Telephone Number: (_____)___________________ (Transferor or Agent) DNR form (June, 2007) FILE WITH RECORDER 542-0960 American LegalNet, Inc. www.FormsWorkflow.com INSTRUCTIONS FOR COMPLETING GROUNDWATER HAZARD STATEMENT The transferor of real property is required to complete this form. The purpose of the statement is to satisfy legal requirements for filing instruments of conveyance of real property with the county recorder (Iowa Code Section 558.69). The Department of Natural Resources does not approve or disapprove of property transfers based on these statements. The statement must be signed by one of the persons transferring the property interest or that person’s agent. An agent signing this form represents the information from transferor to be correct. For the most part the information requested is clear (name, address, etc.). One statement under each of the numbered items (1, 2, 3, 4 and 5) must be checked, and if one or more of the statements checked requires the transferor to provide additional information, that information is to be provided on a separate sheet. Relate the additional information to the specific category of facility (well, etc.) by numbering it with the corresponding number (1, 2, 3, 4, 5). When describing the location of a facility on the property, be reasonably precise, such as a specific distance and general direction from a landmark or corner of the property. A professional survey is not necessary. The following definitions are for use in completing the form. 1. Wells - A “well” is any excavation that is drilled, cored, bored, augered, washed, driven, dug, jetted or otherwise constructed for accessing groundwater or for diverting surface water into the ground, including abandoned wells. “Well” does not include an open ditch or drainage tiles which discharge to the surface. If a well is an “abandoned well” or an “agricultural drainage well,” this must be identified and the status of the well with respect to 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 state of disrepair that continued use is unsafe or impracticable. Abandoned wells are to be properly plugged in accordance with chapter 39 of the rules of the Department of Natural Resources. (567 Iowa Administrative Code, Chapter 39) An “agricultural drainage well” is a well constructed for the purpose of draining, or which drains, water from agricultural land to an aquifer (underground), excluding drainage tile intakes which outlet to the surface. Agricultural drainage wells are required to 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 develop a plan proposing alternatives to the use of the well by July 1, 1998 (See Iowa Code Section 159.29.) 3. Hazardous Wastes - “Hazardous waste” is defined in Iowa Code section 455B.411, 567—141.2 (455B), I.A.C., and federal regulations referenced therein. It is generally defined as waste that poses a threat to human health or the environment. It includes wastes which are ignitable, corrosive, toxic, explosive, violently reactive, or specifically listed as hazardous in the Code of Federal Regulations (40 CFR 261). EXCLUDED are household wastes, agricultural wastes returned to the soil as fertilizers or soil conditioners, agricultural chemicals applied or disposed of by a farmer in accordance with the manufacturer’s instructions, triple-rinsed agricultural chemical containers disposed of by farmers (where the rinsate is used as makeup water in the tankmix and applied at appropriate rates), and other specific materials. Persons are legally required to be aware of hazardous waste laws. 4. Underground Storage Tanks - “Underground storage tank” means one or a combination of tanks, including underground piping connected to the tanks, used to contain an accumulation of regulated substances, and the volume of which is 10 percent or more beneath the surface of the ground. “Regulated substances” include petroleum products and hazardous or toxic materials identified in 567--135.2(455B), I.A.C. Underground storage tank does not include: a. Farm or residential tanks of 1,100 gallons or less capacity used for storing motor fuel for noncommercial purposes. But See 455B.473(4)) b. Tanks used for storing heating oil for consumptive use on the premises where stored. c. Residential septic tanks. d. Pipeline facilities regulated by state or federal law. e. A surface impoundment, pit pond, or lagoon. f. A storm water or wastewater collection system. g. A flow-through process tank. h. A liquid trap or associated gathering lines directly related to oil or gas production and gathering operations. i. A tank in an underground area such as a basement or mine, if the tank is on or above the surface of the floor. j. Pipes connected to the above exclusions. “Tank type” means the material of construction (steel, fiberglass reinforced plastic [FRP], or other [specify]), and any internal or external protection such as a protective coating or wrapping, or cathodic protection. Identify the capacity in gallons and the substance stored in each tank. 2. Solid Waste - “Solid waste” means garbage, refuse, rubbish and other similar discarded solid or semisolid material. It does not include dirt, stone, brick, or similar inorganic material used for fill, as long as no other solid waste is included. See 567--100.2(455B), Iowa Administrative 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 not the disposal is or was regulated by the department. If the transferor or agent has not received notice from the Department of Natural Resources that the disposal site has been deemed to be potentially hazardous, there is no duty to inquire to the department. 5. Private Burial Sites - “Private Burial Site” means one or more graves containing human remains. For each site the transferor shall state the location of the site. For each decedent buried on the property the transferor shall state all known identifying information of that decedent including name, date of death, and date of birth. 6. Filing - This form must be presented to the county recorder when the document to be recorded is filed. The Recorder shall forward the original to the transferee when the recorded instrument is returned. The recorder is not required to keep any copies. *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 (June, 2007) 43-0960 American LegalNet, Inc. www.FormsWorkflow.com