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Sc Me - al ? e ierji i_r t . "e -aieT/Re y c i�?rg' s`'�t'teration ! s – ! ,i -,...._' ti <br />..F ;.+... 3, F it,re�:t-�. ,u±Jail,c:si..J;? <br />r age + <br />�. Are prernises: <br />_ec ^sed by 2DGiiCatli Ue ?ed bV appi;can <br />i f ieased: 'dame of o':'Jner <br />Business address <br />i'�i. � RSO INIAL DATA' <br />A. A.opiicant's L egal ri=me <br />B. Residential Address 2— 5 <br />cif! �� .ate t) � <br />C. Resilidential Telephone Number <br />D. S SN E. Date GI BirFl <br />INCLUDE, WIT APPLICATION, A SITE <br />i� LANO 1 H FAC!LIT' ' Sf- O��r ING <br />PROPrR S L1N ES, SU1L diNGS, f PARKIN LA G SPACES, LOADING DOC \S, F E <br />STORAGE, AND L ANDSCA? INN. <br />V. 1NCLIUDIE, WI APPL CATiON, A M5.00 PROCESS1INIG EEC= <br />tif,/ and affirm tbat al of the information 1 have given i n his aLplic• Lion is tfue aric <br />t he reby, ^•er <br />accurate to the best of my knowledge. 1 further certify and affirm - that i have in n0':� ay <br />attempted to mislead the Cis in this ai Scra p )pl ication by omiiing sacs kr own to me. 3 have reia,d <br />and understand the re- dulations of - the 1 i rk � er /Recycling <br />_ Me JealeriJun� e�i,, <br />Opera i rans'ier Station l icense found in the City of South Bend Municipal Code, Section <br />4 -5 -1 <br />Signature Date <br />