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Scrap Metal Dealer /Junk Dealer /Recycling Operation License Application <br />Page 2 <br />K. Are premises: - Leased by applicant <br />_ ..�_ owned by applicant? <br />If leased: Name of owner T'QAo.%z �.1� c tL r ti�•�. --- <br />Business address <br />Ill. PERSONAL DATA <br />A. Applicant's Leo Name <br />B. Residential Address 1 QL <br />City Ri Staie�_ zip <br />C, <br />C. Residential Telephone plumber <br />D. SSIV 33 �" f02^ 3 Q'�' E. Date of Birth a3 / <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 />Vl. AFFIRMATION <br />1, hereby, certify and affirm that all of the information I have given in this application is true and <br />further accurate to the best of my knowledge. I her certify and affirm that I have in noway <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 />signature <br />