Alcoholic Beverage Contro State of California BEER KEG REGISTRATION SUPPLY ORDER PLEASE READ THE FOLLOWING BEFORE ORDERING •If volume is 100 kegs per month or less, order a one year supply (minimum order 100 tags). By Mail Supplies listed below may be ordered by completing this form and mailing it with the proper fee to your local ABC District Office •If volume is greater than 100 kegs per month, please order a six (6) month supply. From District Office •Please make personal check, cashier's check or money order payable to Department of ABC. Supplies listed below may be obtained in person from your local ABC District Office ITEM PRICE Receipt Books (50 receipts per book) QUANTITY YOUR COST $9.00 Beer Keg Identification Tag Packets (100 tags per packet) $21.00 Total Amount Due PURCHASER INFORMATION 1. ALCOHOLIC BEVERAGE LICENSE NUMBER 2. COUNTY WHERE LICENSE ISSUED 3. LICENSEE(S) NAME(S) 4. LICENSED PREMISES ADDRESS (Street number and name, city, zip code) 5. MAILING ADDRESS (If different from premises address) (Street number and name, city, state, zip code) NORTHERN CALIFORNIA SOUTHERN CALIFORNIA EUREKA, 95501 1105 6th Street, Suite C (707) 445-7229 Del Norte and Humboldt Counties SAN FRANCISCO, 94105 71 Stevenson Street, Suite 1500 (415)356-6500 San Francisco and San Mateo Counties BAKERSFIELD, 93309 4800 Stockdale Highway, Suite 213 (661) 395-2731 Inyo, Kern, and Mono Counties SAN DIEGO, 92101 1350 Front Street, Room 5056 (619) 525-4064 Southern part of San Diego County FRESNO, 93726 3640 East Ashlan Avenue (559) 225-6334 Fresno, Kings, Madera, and Tulare Counties SAN JOSE, 95113 100 Paseo de San Antonio, Rm 119 (408) 277-1200 Santa Clara County INGLEWOOD, 90306 1 Manchester Blvd, Sixth Floor P.O. Box 6500 (310) 412-6311 Southern and western parts of Los Angeles County SAN MARCOS, 92069 570 Rancheros Drive, Suite 240 (760) 471-4237 Northern part of San Diego County OAKLAND, 94612 1515 Clay Street, Suite 2208 (510) 622-4970 Alameda, Contra Costa, and Solano Counties REDDING, 96022 1900 Churn Creek Road, Suite 216 (530) 224-4830 Butte, Glenn, Lassen, Modoc, Plumas, Shasta, Siskiyou, Tehama and Trinity Counties SACRAMENTO, 95834 2400 Del Paso Road, Suite 155 (916) 419-1319 Alpine, Amador, El Dorado, Placer, Sacramento, and Yolo Counties SANTA ROSA, 95404 50 D Street, Room 130 (707) 576-2165 Lake, Marin, Mendocino, Napa, and Sonoma Counties STOCKTON, 95202 31 East Channel Street, Room 168 (209) 948-7739 Calaveras, Mariposa, Merced, San Joaquin, Stanislaus, and Tuolumne Counties YUBA CITY, 95993 950 Tharp Road, Suite 502 (530) 751-8570 Colusa, Nevada, Sierra, Sutter, and Yuba Counties SALINAS, 93907 1137 Westridge Parkway (831) 755-1990 Monterey, San Benito, and Santa Cruz Counties LAKEWOOD, 90712 3950 Paramount Blvd, Suite 250 (562) 982-1337 Southeastern part of Los Angeles County LA/METRO, 90010 3530 Wilshire Blvd, Suite 1110 (213) 736-2005 Central part of City of Los Angeles MONROVIA, 91016 222 East Huntington Drive, Suite 114 (626) 256-3241 Northeastern part of Los Angeles County RANCHO MIRAGE, 92270 42-700 Bob Hope Drive, Suite 317 (760) 568-0990 Imperial County and desert areas of Riverside and San Bernardino Counties SANTA ANA, 92701 28 Civic Center Plaza, Room 369 (714) 558-4101 Orange County SAN LUIS OBISPO, 93401 3220 South Higuera Street, Suite 233 (805) 543-7183 San Luis Obispo and northern part of Santa Barbara County VAN NUYS, 91401 6150 Van Nuys Blvd, Room 220 (818) 901-5017 North and northwestern parts of Los Angeles County VENTURA, 93003 1000 South Hill Road, Suite 310 (805) 289-0100 Ventura and southern part of Santa Barbara County RIVERSIDE, 92501 3737 Main Street, Suite 900 (951) 782-4400 FOR DEPARTMENT USE ONLY SERIAL NUMBER OF BEER KEG TAGS SOLD DATE DISTRICT OFFICE SOLD BY RECEIPT NUMBER ABC-288-K (11/11) American LegalNet, Inc. www.FormsWorkFlow.com