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I' <br /> 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 �E <br /> Business address <br /> III. PERSONAL DATA bs <br /> A. Applicant's Legal Name` 1 <br /> B. Residential Address Ann V lm� <br /> City 3F u& )es)a State_ Zip <br /> C. Residential Telephone Number S 1° <br /> D. SSN ��'°��" 'c E. Date 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. 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 /> SQnature Date <br />