State of California Department of Alcoholic Beverage Control LICENSE ACTION REQUEST Read instructions on reverse before completing. SECTION 1 1. LICENSEE'S NAME 2. LICENSE NUMBER 3. DOING BUSINESS AS (DBA) 4. DISTRICT OFFICE 5. PREMISES ADDRESS 6. LICENSE ATTACHED Yes 7. MAILING ADDRESS No SECTION 2 CANCELLATION I voluntarily cancel my license because I am no longer in business. I understand my license cannot be reactivated or reinstated. 8. CANCELLATION EFFECTIVE Immediately 9. LICENSEE'S SIGNATURE Upon issuance of 10. HOME PHONE NUMBER Other: 11. DATE BUSINESS CLOSED 12. DATE SIGNED ( SECTION 3 ) SURRENDER - Rule 65 I voluntarily surrender my license for a period of not more than one year. I intend to Transfer Reactivate the license. I understand that (a) the license must be renewed at the time renewal fees are due or the license will be automatically canceled; (b) the Department will proceed to cancel my license after one year if not transferred or reactivated; and (c) I must report any change in my mailing address to the Department. 13. SURRENDER EFFECTIVE Immediately 14. LICENSEE'S SIGNATURE Upon issuance of 15. HOME PHONE NUMBER Surrender by Department 16. DATE BUSINESS CLOSED Premises abandoned 17. DATE SIGNED ( SECTION 4 ) SURRENDER OF PRIVILEGES FOR A SPECIAL EVENT 18. SPECIFIC ROOM OR AREA WHERE PRIVILEGES ARE TO BE SURRENDERED 19. DATE TO BE SURRENDERED 20. PERIOD OF SURRENDER (State starting and ending times) (type as X:XX xm) to 21. LICENSEE'S SIGNATURE 22. HOME PHONE NUMBER 23. DATE SIGNED ( SECTION 5 ) REQUEST FOR RETURN OF SURRENDERED LICENSE I request the return of the surrendered license described above. I declare under penalty of perjury that there has been no change in ownership of the licensed business, and the premises possess the same qualifications required for the original issuance of the license. 24. LICENSEE'S SIGNATURE 25. HOME PHONE NUMBER 26. DATE LICENSE NEEDED 27. DATE SIGNED ( ) ABC USE ONLY Letter attached requesting surrender, cancellation or return Accusation pending (Send copy of ABC-231 for cancellations to HQ H&L if accusation pending.) Distribution: Section 2: Original to HQ Lic; copy to District file Section 4: Original to District file ABC-231 (10/08) DATE LICENSE MAILED BY HEADQUARTERS OR RETURNED BY DISTRICT OFFICE Section 3: Original to HQ Lic; copy to District file; copy to suspense file Section 5: Original + 1 copy to HQ Lic; copy to District file American LegalNet, Inc. www.FormsWorkFlow.com