NCG060378 -

Energy, Affneral &
Lund Resources
E14VIRONMENTAL QUALITY
Division of Energy, Mineral, and Land Resources FOR AGENCY USE ONLY
Date Received
Land Quality Section / Stormwater ProgramYear Month Day
National Pollutant Discharge Elimination System (NPDES) 1VED
PERMIT OWNER AFFILIATION DESIGNATION FORM JUL 0 5 2018
(Individual Legally Responsible for Permit)
Use this form if there has been:
STORM&TER PERMITTING
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 (or) Certificate of Coverage
N I C I S I I I I N C I G 0 16 10 3 7 8
2) Facility Information:
Facility name:
Company/Owner Organization:
Facility address:
Revlon Consumer Products
1501 Williamsboro Street
Address
Oxford NC 27565
City State Zip
To find the current legally responsible person associated with your permit, go to this website:
http•//dem nc ,gov/about/divisions/enerQv-inineral-land-resources/energy-mineral-land-permits/storrnwater-program
and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: John
First
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit:
SWU-OWNERAFFIL-23March2017
Swedberg
MI Last
David J
First MI
Page 1 of 2
Hamilton
Last

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:
VP Manufacturing and Plant Manager
Title
1501 Williamsboro Street
Mailing Address
Oxford NC 27565
City State Zip
(919 )603221E David. HamiltonrdRevlon.com
Telephone E-mail Address
( 919 ) 603-2270
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, David J. Hamilton , attest that this application for this change in Owner Affiliation
(person legally responsible for the permit) has been reviewed and is accurate and complete to the best of my
knowledge. I understand that if all required parts of this form are not completed, this change may not be
proce
Signature Date
��; r1�%mss .°35�+ �x •a ra.T's-xr..r��.z
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
Page 2 of 2
S WU-OWNERAFFIL-23Mar2017