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Scrap Metal Dealer/Junk DealerlRecycling Operafion A.pplicaE oG, <br />Page 21 <br />K. Are premises: Leased by applicant Ie .. _._ owned by applicant? <br />If leased: Name of owner C .f {�GtC. ��, ��.t ' ��,'c .�. i - <br />Business address ����`�) �� �-_ �" � L3�- `�- ` . t` .r <br />TAV <br />III. PERSONAL DATA t <br />A. Applicant's Legal Name r <br />B. Residential Address - °()f1f t4(�,' r <br />CityGg if�r l` State Zip ? <br />C. Residential Telephone Numbers <br />D. SSN E. Date of Birth S I1-X1 / e- Loa is 6 <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. AFFIRMA T ION <br />1, 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. 1 fuither certify and affirm that I have in no way <br />attempted to mislead the City in this application by ortiitting facts known to me. I have read <br />and understand the regulations of the Scrap Metal Dealer/Junk Dealer /Recycling <br />Operation/Transfer Staficn license found in the City of South Bend Municipal Code, Section <br />4-51, <br />q-., <br />Q—) s �✓t mate <br />Signature <br />