FV-231-2A PACA License Reinstatement Notice

PACA LICENSE REINSTATEMENT

NOTICE 7. G

INSTRUCTIONS: If all of the information SHOWN ON THE FRONT OF THIS FORM is current and complete, "X" the "With NO Change" box below OR if the information is NOT current or correct,
"X" the "With CHANGE(s)" box and report the appropriate changes or additions in the spaces below. This form must be signed and returned completed, with the total REINSTATEMENT FEES
DUE to be receivedby the anniversarydate. Under "Nature of Business" check the ONE BOX which represents the predominant style of your operations. If there have been changes in ownership,
partners, officers, directors, members and/or managers of LLCs or holders of more than 10 percent of the stock, or in their address, you should include and/or update ALL information requested
for each individual. Missing or incorrect data on the front of this form may be inserted there. Adding and deleting persons should be reported in the space provided below. If license is NOT
being renewed,

explain your reason under "REMARKS"

FRUITS AND VEGETABLES HANDLED
("X" one box) (Item 3 on front)
1.0

Fresh

2. 0

Frozen

and return this form.

QUESTIONS???

call

(202)

-

720-3053.

NATURE OF BUSINESS ("X" one box) (Item 4 on front)

3.0

4.

Both

0

5. 0

Wholesaler

6.0

Commission Merchant

Broker 7. 0

Retailer 8. 0

Processor9. 0 Trucker O. 0

Foo~ G. 0
Service

Grocery

Wholesaler

CHANGES IN OWNERSHIP, PARTNERS,OFFICERS,DIRECTORS,MEMBERS AND OR MANAGERS OF LLCs AND HOLDERSOF MORE THAN 10% OF THE STOCK (If there have been any changes.
"X" the box showing your current operations.)
CHANGES (X)
Add

DATE OF
CHANGE

Delete

LEGAL NAME

(Last

- First - Midd/e

SOCIAL SECURITY
NUMBER

Initial)

REPORTEDOWNERSHIP(Item 5 on front) HAS CHANGED TO:
("X" one box)
CHANGES (X)
Add

("X"

D

Delete

o

I

-

Individual

o

C

= Corp.

o

A = Assoc.

DATE OF
CHANGE

o

T

= Trust

E

-

Estate

o

l

-

limited

Pannership

o

Limited
liability
M = Company

D

TRADE NAME (d/b/a) OR BRANCH

one box)

With NO change

o

FULL HOME ADDRESS

(Street and Number. City, State, and ZIP Code)

Signature

D

With CHANGE(s)

shown

above

P

- Partnership.No. Partners........

LOCATION

and Title of Owner,

TITLE

DIRECTORl
X

% OF
STOCK

IDATE OF CHANGE

(City, State, and ZIP Code I

SIGNATURE

Partner,

Member/Manager (LLC) or Officer
TITLE

Making Application for License Renewal

REMARKS

RETURN APPLICATION AND FEES TO:
USDA-AMS-P ACA
P.O. BOX 790327
ST LOUIS, MO 63179-0327

TO PAY BY CREDIT CARD:

D

VISA

D
D

AMERICAN EXPRESS

D
D

FV-231-2A (01-051

$

DINERSCLUB
ACCT. NO.

The U.S. Department of Agriculture (USDA)prohibits discriminationIn an itl programs and

MO
EXPIRATION

MAKE CHECKS PAYABLE TO "USDA-AMS"
Please include license number being renewed on check.

(For more information about PACA, visit our
website: "www.ams.usda.gov/fv/paca.htm".)

AMOUNT

MASTERCARD
DISCOVER

DATE
NAME OF CARD HOLDER SIGNATURE (Please Printl

According to the Paperwork Reduction Act of 1996, In agency may not conduct or sponsor,
and. person is not required to respond to I collectton of information unle" it displays. valid
OMS control number. The vIIK:tOMS control number for this Wiformltioncollection is
0581-0031.
The time required to comp~te this information collection ta e"imated
to average
3 minutes per response. including the time for reviewing instructions, Harching existing data
sources, gathering Ind maintaining the dati needed. and completing and reviewing the
coUection of information.

YR

activities on the basis of race, color, national origin. gender, religion, age. disability. political
beliefs. sexual orientation, and marital or familv status.
(Not all prohibited b8Ses apply to all
programs..
Persons with disabilities who require Iltemative means for communication of
program inf«mation (Braille,large print. audiotape, etc.. should cOf,.act USDA's TARGET
Center at 202-720-2600
(voice and TOO). To fi~ I complaint of discrimination.write USDA.
Director.Office of Civil Rights. Room 32&.W, Whitten Building, 1400 Independence Avenue.
SW. Washington, DC 20250-9410 or call (202) 720-5964 (voice and TOO). USDA is an equal
opponuntiy provider Ind empJQyer.

~ u.S. GPO: 200&-716-117

Fonn Approved. - OMB No. 0581-0031

According to the Paperwork Reduction
valid OMB control number. The valid
this information collection is estimated
data sources, gathering and maintaining

PACA LICENSE
REINSTATEMENT NOTICE

Act of 1995. no persons arc required to respond to a collection of information unless it displays a
OMB control number for this information collection is 0581 ~031. The time required to complete
to average 3 minutes per response. including the time for reviewing instructions, searching existing
the data needed, and completing and reviewing the collection information.

The U.S. Department of Agriculture (USDA) prohibits discrimination in its programs on the basis of race, color, national origin. gender.
religion. age, disability, political beliefs. sexual orientation. and marital or family status. (Not all prohibited bases apply to all programs).
Persons with disabilities who require alternative means for communicalion of program information (Braille, large print, audiotape, etc.)
should contact the USDA's TARGET Center al 202-720-2600 ( voice and TOO). To file a complaint of discrimination,write USDA.
Director, office of Civil RightS, Room 326-W, Whinen Building, 14th and Independence Avenue, SW, Washington, DC 20250 9410

REINSTATEMENT FEE DUE $50.00

-

I. LICENSE

NO.

2. ANNIVERSARY
DATE

04-10-2007

19951094

NARCISO
8439
SOUTH

BUS:

3. TYPE OF BUSINESS

4501

S. OWNERSHIP

RETAILER

FRESH FRUITS & VEGS

TYPE

6. NO. OF
BRANCHES

INDIVIDUAL

0

GABRIEL

MOUNTAIN

NOTICE TO LICENSEE
REINSTATEMENT
FEE DUE $50.00
Your PACAlicenseexpiredon the anniversarydate
shown aboveas the RENEWALFORMwas not filed.
The license may be reinstatedby returningthis
NOTICEand payingthe required$50 fee within30
days of anniversarydate.
Failure to return this form with all fees due will
result in the termination of your PACA license.

VIEW

GATE

S ALAMEDA

Phone:

I

CA

90280-0000

CA

90058-0000

ST

LOS ANGELES

EIN

4. NATURE OF BUSINESS

Email:

Fax:

STATE IN WHICH INCORPORATED OR FORMED

:

I
DATE
PRINCIPALS
OWNER, PARTNERS, OFFICERS, DIRECTORS, MEMBERS, AND HOLDERS OF MORE THAN 10% OF STOCK
SOCIALSEC.NO.
TITLE
NAME (LAST - FIRST - MIDDLE INITIAL)
HOMEADDRESS
% OF STOCK

-

GABRIEL

NARCISO

I

N
SOUTH

MULTIPLE
GABRIEL

TRADE NAMES AND BRANCHES

GATE

CA

:

PRODUCE

NOTICE TO LICENSEE. You are licensed under the Perishable Agricultural Commodities Act as described above. Uyou are continuing in business, subject to the Act, you must renew the license.
This renewal application must be signed on the reverse and must reach this officeby the anniversary date shown above. See reverse for Instructions on how to report changes, if any have occurred.
PENALTIES: Operations
--- without a license could result in an injunction plus a civilpenalty of 5nOO for each offense plus $350for nch day the offense continues.

---_.

Return rorm with rees to:

FV-2JI-2A USDA -PACA Branch
P.O.BOX 790327
(10-02)
CO:HFDL St. Louis MO 63179 - 0327

Notice to Customers

Making

Payment

by Check: As part ora Depanment

of Treasury initiative. if you pay your account by check, it will be convened into an electronic funds

transfer(EFT). This means Ihe bank will copy your check and use the account information on it to eleclronically debit your account for the amount of the check. The debit from your account
will usually occur within 24 hours. and will be shown on your regular bank account statement. You will not receive your original check back. The bank will destroy your original check. but will
keep the copy of it If the EFT cannot be processed fortechnical reasons, you authorize us to process the copy in place of your original check. I[the EFT cannot be completed because of
insufficient funds, the bank may try 10 make the transfer up 10 2 times at which point your account will be subject to additional administrative charges.