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Scrap Metal Dealer /Junk Dealer /Recycling Operation License Application <br />Page 2 <br />K. Are premises: Leased by applicant ---)-(Owned byapplicant? <br />If leased: Name of owner <br />Business address <br />Ill, PERSONAL DATA <br />A. Applicant's Legal Name . _.� j '� �� o i <br />B. Residential Address 25 �' _ <br />City Fn -t `iIA V>�' '� State 2N Zip '6 <br />C. Residential Telephone Number <br />Flb# <br />D. -SSN- ( f 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. <br />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 />ignatdre <br />Date <br />