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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 <br />Business address <br />Ill. PERSONAL DATA <br />A. Applicant's Legal Name <br />B. Residential Address 2 3 S--Z) Z2 L KO a } <br />City a --e. h cc State d a`f aL Zip V <br />C. Residential Telephone Number 7 `f <br />D. SSN E. Date of Birth Y� ' T* 17 - 19 z <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 />Sign ture Date <br />