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Scrap Metal Dea er /Ju k DeCdier/ ew Cling ooer aaio L Applicatiopt <br />P a. ge 2 <br />K. Are e.emises: Leased by appiiea tt • ' c/ otnrned by 2ppiicant? <br />if ceased: Marne of owner <br />Business address <br />!II. PERSONAL DATA <br />A. ".pplicant's Legal i':ame <br />B. Residential address v;?- 0O 610 �e — T7E G <br />Cry State Z'lj '_ip <br />C. Residential Telephone tiurnber Z-- <br />p nr c�av <br />D. SSN E. Date of Birth - � <br />IV. !NCCL U DE, WI 13 I-I APPLICA T ION, A SIT PLAIN OF THE FACILITY S�IG�1ili�G <br />PRCPE P i Y LINES, BUILDIMGS, PARKING SPACES, L O DING DOCKS, FUEL <br />STCRAG 'E:, AND LANDSCAPING. <br />V. 1NCLUDE, WITH APPLIC'A T ION, A $5.00 PROCESSII`I- -EE <br />V1. AFI IRMATION <br />I, slereby, certify and affirm that all of the information I have given in '=pis application ' is ?rue and <br />accurate to the hest of my knowled I furt ceriiy and affirm th l have in noway <br />attempted to mislead the CiPy in this application by omitting ?acts known to me. I have read <br />and understand the regulations of the Scrap ie €al Dealer /Junk Deaier /Recycling <br />Operation/Transfer Station license - found in the City of South Bend Municipal Code, Section <br />A -51. <br />Signature Date <br />