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Scrap Metal Dealer /Junk Dealer /Recycling Operation License Application <br />Page 2 <br />K. Are premises: <br />Leased by applicant t/ owned by applicant? <br />If (eased: Name of owner <br />Business address <br />III. PERSONAL DATA <br />A, Applicant's Legal Name :) f—tD <br />B. Residential Address ZRD 6 IKboj y1 boo ,S <br />City 6 State Zip <br />C. Residential Telephone Number 7 -Z- 3l - 7-5-9 <br />D. SSN - ° E. Date of Birth - % -- S 3 <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. <br />INCLUDE, WITH APPLICATION, A $5.00 PROCESSING FEE <br />VI. 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 <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 />Signature Date <br />