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Scrap Metal Dealer /Juinik Dealer /Recycling Operaticn <br />P age 2 <br />Leased by applicant owned by applicant? <br />K. Are premises <br />If leased: <br />Ill. PERSONAL DATA <br />License Applic- atlOT�l <br />Name of owner <br />Business address <br />A. Applicant's Legal Nar <br />A] <br />G <br />In <br />Residential Address <br />City c_.�? �6 -,-1, ,l) <br />Residential Telephone Number ..._..,,�.. <br />SSN <br />State Zip , { 4_t <br />E. pate of Birth <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 />1, 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. 1 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 reach <br />and understand the i-dgulations 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 />Date <br />Signature <br />i <br />