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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 sc r`1 e�,.� -^tc' fe S <br />B. Residential Address PC2 <br />city - 15C9 v _ > n. State Zip s g' t✓ <br />C. Residential Telephone Number. <br />D. SSN � L E. Date of Birth j; (e- <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. je Al z 6z— — <br />V. 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 l 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 -59. <br />Signature <br />Date <br />