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i. AppEicatlor <br />Scrap kletai Dalej /JU k Dealer /Recycicpe <br />Page <br />{ c owned ay applicant? <br />K. tyre premises: Leased by applicant <br />If leased: dame of owner <br />Business address <br />III. PE'RSONAL PAT A _. <br />A. Applca j t`s Legal Name /Zis <br />Residential Address _ kJ'`:'" <br />r � ? <br />city c e A) State Zip <br />2-- _ c� — <br />C. Reside tia[ Telephone Dumber ; <br />D- ESN ON r F. Date of Birth <br />IV. INCLUDE, ! ITH APPLICAT[ON, A SITE PLAN OF THE FACILITY SHOWING <br />PROPERT ,LINES, BUILDINGS, PARING SPACES, LOADING DOCKS, FUEL <br />STORAGE „AND LANDSCAPING. <br />V. INCLUDE, iVITH APPLICATION, A $5.00 PROCESSING FEE <br />VL AFI =IRS ATV -N <br />I, hereby, ce ify and affirm that all of the information I have given in this application is true and <br />accurate to tae best of my knowledge. I further certify and affirm that I have in no way <br />attempted tojmislead the City in this application by omitting facts known to rage- I have read <br />and underst� rid the regulations of the Scrap Metal Dealer /junk DealerlRecycling <br />Operation /Transfer Station'; license found in the City of South Bend Municipal Code, Section <br />4-51. <br />uionawre <br />Date <br />