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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 f /� <br />A. Applicant's Legal Name ^1- (2te r S <br />B. Residential Address © t �C :2—Z S-- W- <br />City �c9 v A 7S; S #ate zip <br />C. Residential Telephone Number c1-0 <br />D. SSN a�L 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. ® Al V. INCLUDE, WITH APPLICATION, A $5.00 PROCESSING FEE <br />VI. AFFIRMATION <br />I, hereby, certify and affirm that all of the information 1 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 />h <br />Signature ate <br />