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Abc 251

The document is a form from the Department of Alcoholic Beverage Control for applicants to list any schools, churches, hospitals, public playgrounds, parks, and youth facilities located within 600 feet of the proposed premises. The applicant must provide the name and address of each facility and measure the distance between the facility and premises. The applicant also must sign to acknowledge that any false, misleading, or omitted information may be grounds for denial or revocation of their license.

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51 views1 page

Abc 251

The document is a form from the Department of Alcoholic Beverage Control for applicants to list any schools, churches, hospitals, public playgrounds, parks, and youth facilities located within 600 feet of the proposed premises. The applicant must provide the name and address of each facility and measure the distance between the facility and premises. The applicant also must sign to acknowledge that any false, misleading, or omitted information may be grounds for denial or revocation of their license.

Uploaded by

cafe421
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Department of Alcoholic Beverage Control

STATEMENT RE: CONSIDERATION POINTS

State of California ARNOLD SCHWARZENEGGER, Governor

Applicant: Please complete left side of form, then sign. List the names and addresses of all schools, churches, hospitals, public playgrounds, parks, and youth facilities located within 600 feet of your proposed premises. Measure all distances by direct line from the closest edge of the facility structure to the closest edge of your structure. Continue on reverse if needed.
1. APPLICANT NAME

2. PREMISES ADDRESS (Street number and name, city, zip code)

3. FACILITY NAME/ADDRESS
LTR PERS DATE

DEPARTMENT USE ONLY


DISTANCE FT. NAME SEPARATION FACTORS

1.

LTR

PERS

DATE FT.

2.
NAME

LTR

PERS

DATE FT.

3.
NAME

LTR

PERS

DATE FT.

4.
NAME

LTR

PERS

DATE FT.

5.
NAME

LTR

PERS

DATE FT.

6.
NAME

LTR

PERS

DATE FT.

7.
NAME

LTR

PERS

DATE FT.

8.
NAME

LTR

PERS

DATE FT.

9.
NAME

I acknowledge that any false, misleading or omitted information required in this statement may constitute grounds for denial of the application for the license, or, if the license is issued in reliance upon information in this statement which is omitted, false or misleading, then such misinformation or omission will constitute grounds for revocation of the license so issued.
4. APPLICANT SIGNATURE DATE SIGNED

ABC-251 (12/03)

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