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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 />111. PERSONAL DATA <br />A. Applicant's Legal Name 1'4 c a5 <br />B. Residential Address g2 b.1 .s o <br />City JET ru:- �� State dip '16 c,� / <br />C. Residential Telephone Number 5-1 23L- 7., / <br />D. SSN _3 Q7 -4 A -!-C 4 y!Z 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. 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 -59. <br />�e S <br />Signature <br />Date <br />