APPENDIX 1

RECEIPT FOR SALE OF BEER OR MALT LIQUOR IN KEGS OR SIMILAR CONTAINERS

Date of Sale: ____________________ Keg I.D. No. ____________________

Brand: ____________________ Keg Capacity: ____________________

No. of Kegs: ____________________ Total Gallons: ____________________

Name of Purchaser: ________________________________________

Address: ____________________ Phone No ____________________

Address or location where keg will be located: ____________________

Motor Vehicle Operator's License No.: ____________________

Washington State Identification Card: ____________________

Other Identification: ________________________________________

I declare under penalty of perjury the information provided in this receipt is true and correct and that I am over the legal age to purchase, possess or use malt liquor, that I will not allow the beer or malt liquor purchased and identified by this receipt to be consumed by any person who is under the age of twenty-one (21) except as provided by RCW 66.44.270, and that I will not remove or obliterate the numbered identification label affixed to the keg or similar container.

________________________________________

Signature of Purchaser

Identity of Seller: ________________________________________

Address of Licensed Premises: ________________________________________

NOTICE

It is unlawful for any person under the age of twenty-one (21) years to acquire in any manner, consume or have in his or her possession, any intoxicating liquor, provided that the foregoing shall not apply in the case of liquor given or permitted to be given to such person under the age of twenty-one (21) years by his parent or guardian for beverage or medicinal purposes in the home or administered to him by his physician or dentist for medicinal purposes. A person who signs this receipt with knowledge that any information in the receipt is false commits perjury. Violation of any of the provisions of the Zillah City Ordinance which requires this statement and these terms is a misdemeanor punishable by a fine of not more than $500.00, or by imprisonment not to exceed six months, or by both such fine and imprisonment.