NCS000041_Owner Affiliation Designation Form_20190424

Division of Energy, Mineral, and Land Resources
Land Quality Section / Stormwater Program
N rl. National Pollutant Discharge Elimination System (NPDES)
Energy. Mineral �x PERMIT OWNER AFFILIATION DESIGNATION FORM
Land Reams" (Individual Legally Responsible for Permit)
Use this form if there has been:
FOR AGENCY USE ONLY
Date Received
Year
Month
Day
NO CHANGE in facility ownership or facility name, but the individual
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 changed,
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
N I C I S 10 10 0 0 4 1
2) Facility Information:
Facility name:
Company/Owner Organization:
Facility address:
(or) Certificate of Coverage
N I C I G
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:
httt):fdeci. nc.eov/about/divisions/enerev-mineral-land-resources/energy-mineral-land-t)erinits/storFnwateUrogra
and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: Ken Golder
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit: Fernando H Colombo
First MI Last
Page I of 2
SW U-OWNE RAF F IL-23 March2017

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
❑ 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 a permit) has been reviewed and is accurate and complete to the best of my
knowledge. I rstand t if all required parts of this form are not completed, this change may not be
processed.
C�J y aq o20��
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: htti):Hdeq.nc.Lov/about/divisions/ener¢v-mineral-land-resources/stormwater
Page 2 of 2
S W U-OWNERAFFIL-23Mar2017

CLARIANT CORPORATION
P.O. Box866 CLARIANT
625 East Catawba Avenue
Mount Holly, NC 28120
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