V ABC Permit # U7-41

Virginia Department of Alcoholic Beverage Control • www.abc.virginia.gov • 2901 Hermitage Road • Richmond, VA 23220 • (800)552-3200

APPLICATION AND PERMIT TO PURCHASE INDUSTRIAL ALCOHOL AN D/OR ALCOHOLIC BEVERAGES (For the Year Ending December 31, 2017)

Contact Person: 3Agg-11•11 (21.4fidi—i FFE-

Company Name: OE QA.g._Trtr:Cl\s-C \.) -LTEIZ_A/J A MA t (L5

Business Address: )91(1) (2-,,,,A00._c- LAJ 0

City: ,3A1-Erri State: UA zip: Z9153 Phone:9-0) -7-L1bi3 Email address: 5480-WA KATCLA FRE A. 40v The applicant is engaged in the following business: +1 1DIc!AL-

and manufactures the following products in which alcohol and/or alcoholic beverages are used:

Name of Products Manufactured Kind of Alcohol and/or Alcoholic Beverage Used Vendor Name

ETI-01- A LecA-koi_ ro ? K.605 AA PE-(--A L"--0 No- 1) fk) 0 1-t1ANIIA FM-nal 2) NO rtiAtJUFACTU CA iJ • E-n-tAL- A t_Coti 01— 740 pe_oor. AA PE--1-- A Lex) kA 0 1- 3)

*To be purchased from the following vendor(s):

Name of Vendor Vendor Email Annual Quantity to Purchase

1) AA ()E(4-- AL-CO NO L DILEU . RE-rn i A eP KA(1-rne-o,AAPE tz-• ../31-ti 3aNALI-0^6 2)

3)

4)

Application Fees

Application Fees: 1.5 -110 gallons = $5; more than 110 gallons = $10; for alcoholic beverages add 5% mark-up

Calculating Annual Application Fees for Alcohol and/or Alcoholic Beverages:

Kind of Alcohol/Alcoholic Beverage

Amount (Gallons)

Fees "5% Mark-Up for Alcoholic Beverages

Item Total

0 A Total Fees

*Required Field

**Applications for other alcoholic beverages shall be accompanied by a fee of 5% of the delivered cost to the place designated by the permittee. No

fee shall be charged agencies of the United States or of the Commonwealth of Virginia or eleemosynary institutions.

** 1 of 2 Application and Permitto Purchase Industrial Alcohol and/orAlcoholicBeverages I Revised 4/28/2016

Ethyl Alc. 190 & 200 Proof 350 0.00 0.00

0.00

V ABC Permit #1.1911

Virginia Department of Alcoholic Beverage Control • www.abc.virginia.gov • 2901 Hermitage Road • Richmond, VA 23220 • (800)552-3200

When approved by Virginia Alcoholic Beverage Control this document permits transportation of listed alcohol products into the Commonwealth of Virginia.

Contact Person: .3Aga_ifri4 KAT-41-1 FFer

Delivery Address: 101-1-(1), sLQD

City: 3,4L --111 State: Zip Code:-Z-9 I S3

phone5-roiisz-Z_Lki3

Applicant (signature) : 5ainlz4L. P5ch0

Applicant (print) : Age.A giNTel.t

FOR ABC USE ONLY

Permit Approved

Approved by Date Permit Number

Authorization §§ 4.1-103, 4.1-111, 4.1-200, 4.1-204 and 4.1-229 ofthe Code ofVirginia/ 3 VAC 5-70-60

** 2 of 2 Application and Permitto Purchase Industrial Alcohol and/orAlcoholic Beverages I Revised4/28/2016

12/15/2016 674