OMB No. 1513-0020

OMB No. 1513-0020 (01/31/2009)

FOR TTB USE ONLY

DEPARTMENT OF THE TREASURY

ALCOHOL AND TOBACCO TAX AND TRADE BUREAU

APPLICATION FOR AND CERTIFICATION/EXEMPTION OF LABEL/BOTTLE APPROVAL

(See Instructions and Paperwork Reduction Act Notice on Back)

TTB ID

07165001000281

1. REP. ID. NO. (If any)

643

PART I - APPLICATION

2. PLANT REGISTRY/BASIC PERMIT/BREWER'S NO. (Required)

DSP-CA-15002

3. SOURCE OF PRODUCT (Required)

	Domestic
	Imported

8. NAME AND ADDRESS OF APPLICANT AS SHOWN ON PLANT REGISTRY, BASIC PERMIT OR BREWER'S NOTICE. INCLUDE APPROVED DBA OR TRADENAME IF USED ON LABEL (Required)

Modern Spirits LLC
168 W POMONA AVE

MONROVIA CA 91016

4. SERIAL NUMBER (Required)

07TJ3B

5. TYPE OF PRODUCT (Required)

	WINE
	DISTILLED SPIRITS
	MALT BEVERAGE

6. BRAND NAME (Required)

TRADER JOE'S

8a. MAILING ADDRESS, IF DIFFERENT

7. FANCIFUL NAME (If any)

MOCHA

9. EMAIL ADDRESS

10. FORMULA/SOP NO.
(If any)

11. LAB. NO. & DATE / PREIMPORT NO. & DATE (If any)

18. TYPE OF APPLICATION (Check applicable box(es))

a.	CERTIFICATE OF LABEL APPROVAL
b.	CERTIFICATE OF EXEMPTION FROM LABEL APPROVAL "For sale in _______ only" (Fill in State abbreviation.)
c.	DISTINCTIVE LIQUOR BOTTLE APPROVAL. TOTAL BOTTLE CAPACITY BEFORE CLOSURE ____ _____ (Fill in amount)
d.	RESUBMISSION AFTER REJECTION TTB ID. NO. ______

12. NET CONTENTS

375 MILLILITERS

13. ALCOHOL CONTENT

14. WINE APPELLATION IF ON LABEL

15. WINE VINTAGE DATE IF ON LABEL

16. PHONE NUMBER

(213) 375-3668

17. FAX NUMBER

(213) 375-3668

19. SHOW ANY WORDING (a) APPEARING ON MATERIALS FIRMLY AFFIXED TO THE CONTAINER (e.g., caps, celoseals, corks, etc.) OTHER THAN THE LABLES AFFIXED BELOW, OR (b) BLOWN, BRANDED OR EMBOSSED ON THE CONTAINER (e.g., net contents etc.). THIS WORDING MUST BE NOTED HERE EVEN IF IT DUPLICATES PORTIONS OF THE LABELS AFFIXED BELOW. ALSO, PROVIDE TRANSLATIONS OF FOREIGN LANGUAGE TEXT APPEARING ON LABELS.

PART II - APPLICANT'S CERTIFICATION
Under the penalties of perjury, I declare; that all statements appearing on this application are true and correct to the best of my knowledge and belief; and, that the representations on the labels attached to this form, including supplemental documents, truly and correctly represent the content of the containers to which these labels will be applied. I also certify that I have read, understood and complied with the conditions and instructions which are attached to an original TTB F 5100.31, Certificate/Exemption of Label/Bottle Approval.
20. DATE OF APPLICATION 06/14/2007	21. SIGNATURE OF APPLICANT OR AUTHORIZED AGENT (Application was e-filed)	22. PRINT NAME OF APPLICANT OR AUTHORIZED AGENT MELKON KHOSROVIAN

PART III - TTB CERTIFICATE
This certificate is issued subject to applicable laws, regulations and conditions as set forth in the instructions portion of this form.
23. DATE ISSUED 06/25/2007	24. AUTHORIZED SIGNATURE, ALCOHOL AND TOBACCO TAX AND TRADE BUREAU

FOR TTB USE ONLY

QUALIFICATIONS

Approved despite error(s) in your Warning Statement. When new labels are printed, change the statement so the spelling, punctuation, appearance and capitalization are in compliance with 27 CFR 16, as follows: GOVERNMENT WARNING: (1) According to the Surgeon General, women should not drink alcoholic beverages during pregnancy because of the risk of birth defects. (2) Consumption of alcoholic beverages impairs your ability to drive a car or operate machinery, and may cause health problems.
When new labels are printed, all the mandatory information excluding the alcohol content must appear in printing not smaller than two (2) millimeters. This includes lower case lettering. See 27 CFR 5.33 (5). (bottler information)

STATUS

THE STATUS IS EXPIRED.

CLASS/TYPE DESCRIPTION

VODKA SPECIALTIES

EXPIRATION DATE (If any)

12/25/2007

AFFIX COMPLETE SET OF LABELS BELOW

Image Type:

Brand (front) or keg collar
Actual Dimensions: 1.74 inches W X 4.00 inches H

Label Image: Brand (front) or keg collar

Image Type:

Back
Actual Dimensions: 1.74 inches W X 4.00 inches H

Label Image: Back

TTB F 5100.31 (6/2006) PREVIOUS EDITIONS ARE OBSOLETE