OMB No. 1513-0020

OMB No. 1513-0020

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

23096001000372

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

140

PART I - APPLICATION

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

DSP-PA-20081

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)

Lawrenceville Distilling Company, Confluence Distilling, LLC
5410 HARRISON ST

Pittsburgh PA 15201

LAWRENCEVILLE DISTILLING CO. (Used on label)

4. SERIAL NUMBER (Required)

230406

5. TYPE OF PRODUCT (Required)

	WINE
	DISTILLED SPIRITS
	MALT BEVERAGE

6. BRAND NAME (Required)

BACK CREEK

8a. MAILING ADDRESS, IF DIFFERENT

7. FANCIFUL NAME (If any)

WHEATED BOURBON

9. FORMULA

10. GRAPE VARIETAL(S) (Wine Only)

N/A

14. 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. ______

11. WINE APPELLATION (If on label)

12. PHONE NUMBER

(412) 378-4147

13. EMAIL ADDRESS

15. 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.
16. DATE OF APPLICATION 04/06/2023	17. SIGNATURE OF APPLICANT OR AUTHORIZED AGENT (Application was e-filed)	18. PRINT NAME OF APPLICANT OR AUTHORIZED AGENT JOSEPH DEGROOT

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.
19. DATE ISSUED 05/08/2023	20. AUTHORIZED SIGNATURE, ALCOHOL AND TOBACCO TAX AND TRADE BUREAU

FOR TTB USE ONLY

QUALIFICATIONS

Please note that this approval is for the single label attached to this COLA. No other labels may appear on the container.
Permission granted to black out the noncompliance information on the label. The label must appear on the container as it is shown on this application with the text blacked out in the manner you have chosen. (Cover "bourbon" in the puffery.)
This certificate is operative for the release of not more than the following number of bottle cases/ kegs. (10 cases)
This use-up authorizes the depletion of product and labels that are currently in existence as of the date the use-up was requested. No additional product may be made and no additional labels may be printed.
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.

STATUS

THE STATUS IS EXPIRED.

CLASS/TYPE DESCRIPTION

WHISKY

EXPIRATION DATE (If any)

11/03/2023

AFFIX COMPLETE SET OF LABELS BELOW

Image Type:

Brand (front) or keg collar
Actual Dimensions: 8 inches W X 5.25 inches H

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

TTB F 5100.31 (06-2016) PREVIOUS EDITIONS ARE OBSOLETE