OMB No. 1513-0020  (07/31/2015)
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
16159001000584

1. REP. ID. NO. (If any)
CT
137

OR
01

PART I - APPLICATION
2. PLANT REGISTRY/BASIC PERMIT/BREWER'S NO. (Required)
DSP-CA-131
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)

LEVECKE CORPORATION
10810 INLAND AVE

MIRA LOMA CA 91752

OL' GLORY BEVERAGES (Used on label)
4. SERIAL NUMBER (Required)
160024

5. TYPE OF PRODUCT (Required)
WINE
DISTILLED SPIRITS
MALT BEVERAGE

6. BRAND NAME (Required)
OL' GLORY
8a. MAILING ADDRESS, IF DIFFERENT
7. FANCIFUL NAME (If any)
9. EMAIL ADDRESS
 
10. GRAPE VARIETAL(S) (Wine Only)
N/A
11. FORMULA
2r
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
1 LITER
1.75 LITERS
100 MILLILITERS
200 MILLILITERS
375 MILLILITERS
50 MILLILITERS
750 MILLILITERS
13. ALCOHOL CONTENT
40
14. WINE APPELLATION IF ON LABEL
15. WINE VINTAGE DATE IF ON LABEL
16. PHONE NUMBER
(951) 681-8600
17. FAX NUMBER
(951) 681-8666
19. SHOW ANY INFORMATION THAT IS BLOWN, BRANDED, OR EMBOSSED ON THE CONTAINER (e.g., net contents) ONLY IF IT DOES NOT APPEAR ON THE LABELS AFFIXED BELOW. ALSO, SHOW 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
06/07/2016
21. SIGNATURE OF APPLICANT OR AUTHORIZED AGENT
(Application was e-filed)
22. PRINT NAME OF APPLICANT OR AUTHORIZED AGENT
JOSEPH LEVECKE
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
06/21/2016
24. AUTHORIZED SIGNATURE, ALCOHOL AND TOBACCO TAX AND TRADE BUREAU
Authorized Signature

FOR TTB USE ONLY
QUALIFICATIONS
TTB has not reviewed this label for type size, characters per inch or contrasting background. The responsible industry member must continue to ensure that the mandatory information on the actual labels is displayed in the correct type size, number of characters per inch, and on a contrasting background in accordance with the TTB labeling regulations, 27 CFR parts 4, 5, 7, and 16, as applicable.
When new labels are printed, the alcohol content statement must be changed to one of the following: "Alc. ___% by Vol.."," Alc. by Vol.. __%", ___% Alc. by Vol.." or "___% Alc. / Vol". See 27 CFR 5.37. ("Alc" is misspelled)
INFORMATION RETRIEVED FROM THE QR CODE MUST BE IN COMPLIANCE WITH ALL LABELING AND ADVERTISING REGULATIONS.

STATUS
THE STATUS IS APPROVED.

CLASS/TYPE DESCRIPTION
BLENDED WHISKY

EXPIRATION DATE (If any)

AFFIX COMPLETE SET OF LABELS BELOW

Image Type:

Brand (front)
Actual Dimensions: 10.52 inches W X 10.47 inches H


Note: The image below has been reduced to fit the page. See actual dimensions above.
Label Image: Brand (front)




TTB F 5100.31  (07/2012) PREVIOUS EDITIONS ARE OBSOLETE