Fillable Groundwater Hazard Statement Form Attachment 1 REAL ESTATE TRANSFER - GROUNDWATER HAZARD STATEMENT

Fill Online, Printable, Fillable, Blank Groundwater Hazard Statement Form Attachment 1 REAL ESTATE TRANSFER - GROUNDWATER HAZARD STATEMENT Form

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Groundwater Hazard Statement Form Attachment 1 REAL ESTATE TRANSFER - GROUNDWATER HAZARD STATEMENT

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FILE WITH RECORDER DNR form 542-0960 – Attachment #1 (July 18, 2012)
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)
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 IS TRUE AND CORRECT.
Signature: _______________________________________ Telephone No.: (_____)_____________
(Transferor or Agent)
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Groundwater Hazard Statement Form Attachment 1 REAL ESTATE TRANSFER - GROUNDWATER HAZARD STATEMENT

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Completed 28 June 2020

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