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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 <br /> c <br /> B. Residential Address StIS� <br /> city EC. Q 0a I CQ- State Af, Zip ( � <br /> C. Residential Telephone Nu-3 1 Number .L9� " �U I ' (QD I q CO � )(69- 801 - (0112- <br /> D. SSN -P2 '1 <br /> i J- -7 2-- -/ C� E. Date of Birth 0(-o " ( 2' (9 Co(p <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 /> Signature i Date <br />