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Scrap Metal Dealer/Junk Dealer /Recycling Operation License Application <br />Page 2 <br />K. Are premises: Leased by applicant ed by applicant? <br />If leased: Name of owner <br />Business address <br />l {[. PERSONAL DATA <br />A. Applicant's Legal Name <br />B, Residential Address <br />C. <br />State <br />Residential Telephone Numbers �� f - <br />SSN <br />Zip <br />E. Date of Birth 1,2_2q_50,? <br />IV. INCLUDE, WITH APPLICATION, A SITE PLAN OF THE FACILITY SHOWING <br />PROPERTY LINES, BUILDINGS, PARKING SPACES, LOADING DOCKS, FUEL <br />STORAGE, AND LANDSCAPING. ry" &W Q Pd n D-A- -ri le- <br />V. INCLUDE, WITH APPLICATION, A $5.00 PROCESSING FEE <br />VI. AFFIRMATION <br />f, hereby, certify and affirm that all of the information I have given in this application is true and <br />accurate to the best of my knowledge. i further certify and affirm that I have in no way <br />attempted to mislead the City in this application by omitting facts known to me. I have read <br />and understand the regulations of the Scrap Metal Dealer /Junk Dealer /Recycling <br />Operation/Transfer Station license found in the City of South Bend Municipal Code, Section <br />4 -59. <br />Signature <br />a Date <br />