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Scrap Metal Dealer /Junk Dealer /Recycling Operation License Application <br />Page 2 <br />IV. <br />V <br />VI <br />K. Are premises: Leased by applicant owned by applicant? <br />If leased: Name of owner xt-fo'ele r <br />Business address z <br />PERSONAL DATA <br />A. Applicant's Legal Name f C/1 A <br />B. Residential Address 7 � .2-2- <�k- <br />city } j.__t _ State' Zip 7 G <br />C. Residential Telephone Number <br />D. SSN _ 2, <br />E. Date of Birth c:5"A ' r. ` <br />INCLUDE, WITH APPLICATION, A SITE PLAN OF THE FACILITY SHOWING <br />PROPERTY LINES, BUILDINGS, PARKING SPACES, LOADING DOCKS, FUEL <br />STORAGE, AND LANDSCAPING. <br />INCLUDE, WITH APPLICATION, A $5.00 PROCESSING FEE <br />AFFIRMATION <br />I, 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 -51. <br />Signature <br />/— c'—/' % <br />Date <br />