Department of Alcoholic Beverage Control APPLICATION/PERMIT FOR PRIVATE WAREHOUSE State of California ARNOLD SCHWARZENEGGER, Governor Instructions: This form is required for storing alcoholic beverages (other than state tax-paid beer and wine) in a private warehouse. (State tax-paid beer and wine may be stored any place in the state, and no additional license is needed by the licensee or the person furnishing or providing the storage space.) (Section 23106 ABC Act and Rule 76, California Code of Regulations.) Complete items 1-8 and submit this form with the $50 fee to your ABC District Office. This application is approved and the private warehouse permit granted when bearing the signature of a supervisor. The approved copy shall be posted at all times at a convenient place inside and near the entrance to the warehouse. If you no longer require the permit, send written notification to the District Office with the original Form ABC-241 attached. LICENSE NUMBER RECEIPT NUMBER FEE PAID $50.00 1. LICENSEE NAME 2. LICENSED PREMISES ADDRESS 3. ADDRESS OF PRIVATE WAREHOUSE 4. PRIVATE WAREHOUSE IS MAINTAINED BY (Name) 5. 6. DATE LEASE EXPIRES I own the private warehouse premises I lease the private warehouse premises 7. STORAGE SPACE IS IN Basement Garage House Other: 8. LICENSEE SIGNATURE TITLE DATE SIGNED FOR DEPARTMENT USE ONLY The above-described premises was inspected on satisfactory. RECOMMENDATION and found to be Approved DATE SIGNED SUPERVISOR SIGNATURE Approved INVESTIGATOR SIGNATURE DATE SIGNED Denied Denied Distribution: Original - Licensee; Copy - District file; Copy - Private Warehouse Permits file/binder; Copy - Headquarters - Cashier ABC-241 (12/03) American LegalNet, Inc. www.FormsWorkflow.com