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Scrap Metal Dealer /Junk Dealer /Recycling Operation License Application <br />Page 2 <br />K. Are premises: <br />Leased by applicant --)k— owned by applicant? <br />If leased: Name of owner - <br />Business address <br />III. PERSONAL DATA <br />r <br />A. Applicant's Legal Name _ 'la G <br />,B, Residential Address <br />City � c��- State 1__ Zip <br />C. Residential Telephone Number <br />E. Date of Birth <br />D. SSN <br />IV. <br />INCLUDE, WITH APPLICATION, SITE PLAN OF THE FACILITY SHOWI <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 />I, hereby, certify and affirm that all of the information I given in <br />t ha to ion is way rue and <br />accurate to the best of my knowledge. I further certify and affirm <br />attempted to mislead the City in this application by omitting facts <br />Dealer /Recycl ag have read <br />and understand the regulations of the Scrap Metal Dealer/Junk <br />Operation/Transfer Station license found in the City of South Bend Municipal Code, Section <br />4 -51: <br />- -09 <br />Date <br />Signature <br />