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Scrap Metal Dealer /Junk Dealer /Recycling Operation License Application <br />Page 2 <br />K. Are premises: Leased by applicant _Z owned by applicant? <br />If leased: Name of owner <br />Business address <br />113. PERSONAL DATA <br />A. Applicant's Legal Na <br />B. Residential Address <br />City 1)0uAat I C._ Stated Zip 4-461 -1 <br />C. Residential Telephone Number - -- .... C Dci- a o z —"' g g <br />D. SSN B. Date of Birth 0 0 is 3 j V5 to <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 />81 <br />VI. <br />INCLUDE, WITH APPLICATION, A $5.00 PROCESSING FEE <br />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 />A <br />2SA <br />Signature v Date <br />