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Scrap MeW Healer /Junk Dealer/Recycling Operation License Application <br />Page 2 <br />K. Are premises: Leased by applicant owned by applicant? <br />N leased: Name of owner <br />Business address <br />ill. PERSONAL DATA <br />A. •Appitcarrfs. Legal4ave <br />B. Residential Address . Cl -73-0 c!:�c -2- L S- <br />City Sate -Do Zips <br />C. Residential Telephone Number _ - -n>, C-/-o -- Tr Yp 2 <br />D. SSN 26- E. Date of Birth <br />s <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. PAl g r &- -- <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 afftrm that i have in no way <br />attempted to mislead the City in this application by omitting facts known to M. I have read <br />and understand the regulations of the Strap Metal Dealer /Junk Dealer/Recycling <br />Operationfrransfer Station license found In the City of South Bend Municipal Code, Section <br />4-51. <br />S� Date <br />