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i <br />Scrap Metal'Dea#er /Junk DealerlRecyciing Operation License Application <br />Page 2 <br />K. Are premises: _.._ leased by applicant L".) owned by applicant? <br />IV, <br />V. <br />If leased: Name of owner <br />Business address <br />PERSONAL DATA <br />A. Applicant's t eo Name <br />S. Residential Address <br />City <br />I <br />State e-LA Zip <br />C Residential Telephone Number <br />D. SSN �Cl -�., F g � - E. Date of Birth -J.2=-- <br />INCLUDE, WITH APPLICATION, A SITE PLAN OF THE FACILITY SHOWING <br />PROPERTY LINES, BUILDINGS, PARKING SPACES, LOADING " OCK FU <br />STORAGE, AND LANDSCAPING. ;�� enaos FUEL <br />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 t 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 />4-5? <br />f <br />Signature <br />