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From:CiTY OF SOUTH BEND CITY CLERK 5742359173 11/22/2010 15:40 #129 P.0031003 <br />Scrap Metal Dealer /Junk Dealer /Recycling Operation License Application <br />Page 2 <br />K. Are premises: Leased by applicant <br />If leased: Name of owner <br />Susfness address <br />111. PERSONAL DATA j <br />A. Applicant's Legal Name <br />owned by applicant's <br />B. Residential Address <br />City State Zip <br />C. Residential Telephone (dumber <br />D, SSN 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. 0 tj F,' jr-- <br />V <br />V1 <br />INCLUDE, WITH APPLICATION, A $6.00 PROCESSING FEE <br />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, Sectlon <br />r .; / <br />, <br />Signature f Date <br />43)3 z <br />