Name of Property Owner or Operator:                                                           
Address and Telephone Number:                                                                   
Type of Operation:
Salvage Yard           Junkyard           Automobile Graveyard       
Type of Business:
Sole Proprietor         Partnership         Corporation         Other (Specify)      
State Sales Tax No.:                                                                                   
Brief Description of Operation:                                                                 
Physical Boundaries of Operation:  Attach a plot or drawing with physical dimensions designated.
Method of Screening:
Fence       Planting       Natural Objects         Other Appropriate Objects      
"I Certify that the above described establishment or expansion is in compliance with the provisions of Chapter 110 of the code of ordinances for the county and the rules and regulations governing screening of salvage yards, junkyards and automobile graveyards.  This certificate does not imply approval or permission to acquire, handle, store, dispose of or deal in toxic or hazardous wastes."
Sebastian County Judge or Representative:                                                 
Certification Denied:                                                                                       
Denied; Pending Further Action: