NCS000041_Owner Affiliation Designation_20190507

N
Division of Energy, Mineral, and Land Resources
Land Quality Section / Stormwater Program
National Pollutant Discharge Elimination System (NPDES)
Energy. Mineral & PERMIT OWNER AFFILIATION DESIGNATION FORM
Land Resources _
ENVIRONMENTAL OVALITY t111U1V1UUQ1 L-V dIly RI1d,jJV11,1U1V 1U1 ren111L)
FOR AGENCY USE ONLY
Date Received
Year
Month
Day
&A
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Use this form if there has been: Sp
NO CHANGE in facility ownership or facility name, but the i al
who is legally responsible for the permit has changed.
If the name of the facility has changed, or if the ownership of the facility has changeal'�rjic
do NOT use this form. Instead, you must fill out a Name -Ownership Change Form
and submit the completed form with all required documentation.
What does "legally responsible individual" mean?
The person is either:
• the responsible corporate officer (for a corporation);
• the principle executive officer or ranking elected official (for a municipality, state, federal or other public
agency);
• the general partner or proprietor (for a partnership or sole proprietorship);
• or, the duly authorized representative of one of the above.
1) Enter the permit number for which this change in legally Responsible Individual ("Owner Affiliation")
applies:
Individual Permit (or) Certificate of Coverage
N I C I S 10 0 0 0 1 N I C I G
2) Facility Information:
Facility name:
Company/Owner Organization:
Facility address:
Mount Holly West Facility
Clariant Corporation
625 E Catawba Ave
Address
Mount Holly NC 28120
City State Zip
To find the current legally responsible person associated with your permit, go to this website:
http://deg.nc.goy/about/divisions/ener y-mineral-land-resources/energy-mineral-land-permits/stormwatgLprograr
and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual:
Ken Golder
First MI Last
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit:
Fernando H Colombo
First MI Last
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S WU-OWNERAFFIL-23March2017

NPDES Stormwater Permit OWNER AFFILATION DESIGNATION Form
(if no Facility Name/Ownership Change)
5) Reason for this change:
A result of:
If other please explain:
Head of Operations - North America
Title
625 E Catawba Ave
Mailing Address
Mount Holly NC 28120
City State Zip
( 704 ) 822-2100 [e-mail]
Telephone E-mail Address
(704 ) 330-9663
Fax Number
0✓ Employee or management change
Inappropriate or incorrect designation before
❑ Other
The certification below must be completed and signed by the permit holder.
PERMITTEE CERTIFICATION:
1 Fernando Henrique Colombo , attest that this application for this change in Owner Affiliation
(person legally responsib e permit) has been reviewed and is accurate and complete to the best of my
knowledge. I �rsland t if all required parts of this form are not completed, this change may not be
processed.
Date
PLEASE SEND THE COMPLETED FORM TO:
DEMLR - Stormwater Program
Dept. of Environmental Quality
1612 Mail Service Center
Raleigh, North Carolina 27699-1612
For more information or staff contacts, please call [phone] or visit the website
at: http://deg.nc.gov/about/divisions/energy-mineral-land-resources/stormwater
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SWU-OWNERAFFn.-23Mar2017