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De 'lUlik Dealer/Recycling Opera tion Ucer'Se.,�kDON • or! <br />U <br />P2.ge —11 . - it I - ca <br />i I <br />f leased: <br />Owned by applicant? <br />I eased by applicant <br />Name of o <br />3usiness address <br />PERSONAL DATIA <br />A. <br />B. <br />C. <br />D. <br />Applicant's ! =gal 'Name <br />4 `// c_ /7 e_ <br />-Residential Address S7 o 0 A— <br />city I -7i 1�6 <br />Resid - telephone Number <br />SSN 0/I- e_ - (L- E. Date of Birth <br />- U <br />'V <br />INCLUDE, WITH APPLA1CATj' A SITE 1 OF THE FACILITY SHO'VVING <br />'PROPER i Y LINES, BUILDiNGS, PARKING SPACE'S, LOADING DOCKS, FUE1 <br />STORAGE, AND LANDSCAPING. <br />E <br />--kie premises <br />- <br />INCLUDE-, VVITH APPUCATION, A $5.00 PROCESSING IFEE <br />VL AFFiRMAT It: N <br />i j <br />I. hereby, certiN and affirrnlhat all o the information 1 havie given in thiis aippiicattion is true amid <br />accuraie to the best of my knowledge. I fuirther c- 'ify and affirinn that 'nave in noway <br />rT <br />attempted of mislead the C in this application by orni"Itinn - Facts mown to me. 1 have read <br />and understand the regulations of the -Scrap Metal Dealfer/Junlk Dealler/Recycling <br />1 14enation/Trans - fer -Station license found in the City <br />of south Bend Municipal Code, Section <br />- -5 <br />Signature G ate <br />