NCC231153_FRO Submitted_20230424

F U Q JAY �.'A P I N,
Financial Responsibility/Ownership Form SPCA
See TOFV LDO,Section§9-1407 SOIL EROSION&SEDIMENTATION CONTROL and Town Standards and Specifications for
additional details.
Part A.
1. Project Name CCL LABEL FACILITY
2. Location of land-disturbing activity: Highway/Street 1599 Dash Drive
3.Approximate date land-disturbing activity will commence: January 2, 2023
4. Type of development(residential,commercial, industrial, institutional,etc.): Industrial
5. Total acreage disturbed or uncovered (including off-site utilities and borrow/waste areas): 12.93 ac
6. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name David Laverde E-mail Address dlaverde(c�cclind.com
Telephone Cell# [phone]
7. Landowner(s)of Record(attach accompanied page to list additional owners):
CCL Label, Inc. [e-mail]
Name E-mail Address
161 Worcester Road, Suite 403 161 Worcester Road, Suite 403
Current Mailing Address Current Street Address
Framingham, MA 01701-5315 Framingham, MA 01701-5315
City State Zip City State Zip
8. Deed Book No. 19111 Page No. 757 Provide a copy of the most current deed.
Part B.
1. Person(s)or firm(s)who are financially responsible for the land-disturbing activity(Provide a comprehensive list of all
responsible parties on an attached sheet. Include requested Information):
CCL Label, Inc. [e-mail]
Name E-mail Address
161 Worcester Road, Suite 403 161 Worcester Road, Suite 403
Current Mailing Address Current Street Address
Framingham, MA 01701-5315 Framingham, MA 01701-5315
City State Zip City State Zip
Telephone [phone]
Town of Fuquay-Varina E 401 Old Honeycutt Road, Fuquay-Varina, NC 27526
[phone] E fuquay-varina.org

2. (a) If the Financially Responsible Party is not a resident of Wake County, identify a designated agent in Wake County to
receive any notice, process, pleading in any action or legal proceeding arising out of any matter relating to the Town of
Fuquay-Varina Land Development Ordinance and/or Land Disturbance Permit:
Corporate Service Company [e-mail]
Name E-mail Address
2626 Glenwood Avenue, Suite 550 2626 Glenwood Avenue, Suite 550
Current Mailing Address Current Street Address
Raleigh, NC 27608 Raleigh, NC 27608
City State Zip City State Zip
Telephone [phone]
(b) If the Financially Responsible Party is a Partnership or other person engaging in business under an assumed name,
attach a copy of the Certificate of Assumed Name. If the Financially Responsible Party is a Corporation, give name
and street address of the Registered Agent:
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone
The above information is true and correct to the best of my knowledge and belief and was provided by me under oath
(This form must be signed by the Financially Responsible Person if an individual or his attorney-in-fact,or if not an
individual, by an officer, director, partner, or registered agent with the authority to execute instruments for the Financially
Responsible Person). I agree to provide corrected information should there be any change in the information provided
herein.
Sean Washchuk, Treasurer
Type or pr. t name yitle;or; 't
c2/// December 2, 2022
Signature Date
I, Suzana Furtado , a Notary Public of the City of Toronto
Province of Ontario , hereby certify that Sean Washchuk appeared personally
before me this day and being duly sworn acknowledged that the above form was executed by him.
Witness my hand and notarial seal,this 2nd day of December , 2022
—Notary
Seal June 19, 2023
My commission expires
Suzan Dos Anjos Medeiros Furtado,
Notary Public, City of Toronto, limited
to the attestation of instruments and
the taking of affidavits, for CCL
Industries Inc. and its subsidiaries.
Expires June 19, 2023.