Licensing and Regulation PO Box 43098 Olympia WA 98504-3098 www.lcb.wa.gov Phone: (360) 664-1600 Fax: (360) 753-2710 License Number Trade Name UBI Number Grocery Store Inventory Acknowledgment Grocery stores must maintain a minimum of $3,000 wholesale value of food products for human consumption, not to include soda pop, beer, or wine (RCW 66.24.360). Estimated cost of inventory (does not include soda pop, beer or wine): $ I certify by my signature below that I/we currently meet and will continue to maintain the above requirements as long as I/we hold a Beer/Wine Grocery Store license. Print Name Signature of Applicant (Sole Proprietor, Partner, Officer, LLC Member/Manager) Date LIQ 295 7/15 *LCB LIQ295* American LegalNet, Inc. www.FormsWorkFlow.com