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Apr, 2. 2009 4:OOPM OFFICE OF IHE CITY CLERK <br />No, 1689 P, 3 <br />Scrap Metal Dealer/Jrtnk 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 />lll. PERSONAL DATA `,,, (~,, <br />A. Applicant's legal Name ~~ ~>i 1C~`~..~ <br />B. Residential Address ~~„~1.,, A+~1r,~e©~ 1,~~-.!~>` <br />~. ~~' <br />City ~~ GI?state ~ ~ Zip _ <br />C. Residential Telephone Number ~ ~~ ! ~ ~ I~ <br />D. SSN ~~~ ~ 5 Z--~ . _ E. Date of birth ~~ ~ - `~~--~1T---= <br />I'V. INCLUDE, WITH APPLICATION, A SITE PLAN OF THE FACILITY SHOWING <br />PROPERTY L1NES, BUILDINGS, PARKING SPACES, L~IADING DOGKS, FUEL <br />ST4l~,AGE, 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 taste and <br />accurate to the best of my knowledge. }further certify and affirm that i have in no way <br />attempted to.mislead the City in this application by amitfing facts Known to me. I have read <br />and understand the regulations of the Scrap Meta[ Dealer/Junk DealerlRecycling <br />OperatianlTransferStation license found in the City of South Bend Municipal Code, Section <br />4-51. <br />~'~ <br />4 <br />~' Sign „ re <br />^~ ~~ <br />Date <br />