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Scrap Metal Dealer/Junk Dealer/Recycling Operation License Application <br />Page 2 <br />K. Are premises: X Leased by applicant owned by applicant? <br />If leased: Name of owner Kuert Concrete Tnc <br />Business address 3402 Lincolnway West, South Bend, IN.46628 <br />III. PERSONAL DATA <br />A. Applicant's Legal Name <br />David L. Schrock <br />B. Residential Address 66448 Cedar Rd <br />City Wakarusa State IN Zip 46573 <br />C. Residential Telephone Number (574) 633-4131 <br />° D. SSN <br />E. Date of Birth 11 /02/56 <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 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 />Opera#ion/Transfer Station license found in the City of South Bend Municipal Code, Section <br />4-51. <br />~~ ~ ©(~ 0 <br />Signature Date <br />