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Scrap Metal Dealer/Junk Dealer/Recycling Operation License Application <br />Page 2 <br />K. Are premises: Leased by applicant ~_ owned by applicant? <br />if leased: Name of owner <br />Business address <br />III. PERSONAL DATA ~ ~ ~ . <br />A. Applicant's Legal Name <br />B. Residential Address ~0 <br />City ~~/d IC'~~ ~ State ~- Zip ~(~il~ ~ ~i' <br />C. Residential Telephone Number ~5 1 `'l~ r ~~rJ~~ <br />D. SSN _ _ E. Date of Birth ~2. ~7T~~~ <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 />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 I 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 Ciry of South Bend iviunicipai~Code, Section <br />4-51. <br />2- ~ -O9 <br />Date <br />