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Scrap Metal Dealer/Junk Dealer/Recycling Operation License Application <br /> Page 2 <br /> K. Are premises: Leased by applicant owned by applicant? <br /> If leased: Name of owner <br /> Business address <br /> III. PERSONAL DATA <br /> A. Applicant's Legal Name C- �Q CA <br /> e <br /> B. Residential Address -Q� - <br /> City �t��' (_�©.I r2 State i )c_ Zip <br /> C. Residential Telephone Number ct A09- (oilZ <br /> D. SSN 313° -12-^ 73S9 E. Date of Birth 0(0 - 12- (CICO(jo <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. <br /> V. INCLUDE, WITH APPLICATION, A $5.00 PROCESSING FEE <br /> VI. 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 /> to ZvI� <br /> Signature —TDate <br />