NCGNE0622 -

Division of Energy, Mineral & Land Resources FOR AGENCY USE ONLY
1 • Date Received
Land Quality Section/Stormwater Permitting Year Month I Da
National Pollutant Discharge Elimination System
NCDENR
NO C—L— DERnRT - or
ENVIRONMEW— N—R-RE—RCE] PERMIT NAME/OWNERSHIP CHANGE FORM
I. Please enter the permit number for which the change is requested.
NPDES Permit (or) Certificate of Coverage
Revised Jan. 27, 2014
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II. Permit status prior to requested change.
a. Permit issued to (company name):
Fresenius Kabi USA, Inc
b. Person legally responsible for permit:
Tracy Hottovy
First MI Last
Director Of Operations
RECEIVED
Title
5200 Corporate Parkway
AUL 3 n ?n���
Permit Holder Mailing Address
Wilson NC 27893-9412
DENR-LAND QUALITY
City State Zip
STORMWATER PERMITTING
[phone] [phone]
Phone Fax
c. Facility name (discharge):
Fresenius Kabi USA LLC
d. Facility address:
5200 Corporate Parkway
Address
Wilson NC 27893-9412
City State Zip
e. Facility contact person:
Gregory M Mcguire [phone]
First / MI /Last Phone
III. Please provide the following for the requested
change (revised permit).
a. Request for change is a result o£
❑ Change in ownership of the facility
❑ Name change of the facility or owner
If other please explain: Name Change for Person Legally Responsible for the Permit
b. Permit issued to (company name):
Fresenius Kabi USA LLC
c. Person legally responsible for permit:
Andre Grebenstein
First MI Last
Plant Manager
Title
5200 Corporate Parkway
Permit Holder Mailing Address
Wilson NC 27893-9412
City State Zip
[phone]
Phone E-mail Address
d. Facility name (discharge):
[e-mail]
e. Facility address:
5200 Corporate Parkway
Address
Wilson NC 27893-9412
City State Zip
f. Facility contact person:
Gregory M Mcguire
First MI Last
[phone] greg.mcguirepfresenius-kabi.com
Phone E-mail Address
Revised Jan. 27, 2014

NPDES PERMIT NAME/OWNERSHIP CHANGE FORM
Page 2 of 2
IV. Permit contact information (if different from the person legally responsible for the permit)
Permit contact: Gregory M Mcguire
First MI Last
Eh&S Manager
Title
5200 Corporate Parkway
Mailing Address
Wilson NC 27893-9412
City State Zip
[phone] greg.mcguire(a-),fresenius-kabi.com
Phone E-mail Address
V Will the permitted facility continue to conduct the same industrial activities conducted prior
to this ownership or name change?
® Yes
❑ No (please explain)
VI. Required Items: THIS APPLICATION WILL BE RETURNED UNPROCESSED IF ITEMS
ARE INCOMPLETE OR MISSING:
❑ This completed application is required for both name change and/or ownership change
requests.
❑ Legal documentation of the transfer of ownership (such as relevant pages of a contract deed,
or a bill of sale) is required for an ownership change request. Articles of incorporation are
not sufficient for an ownership change.
The certifications below must be completed and signed by both the permit holder prior to the change, and
the new applicant in the case of an ownership change request. For a name change request, the signed
Applicant's Certification is sufficient.
PERMITTEE CERTIFICATION (Permit holder prior to ownership change):
I, , attest that this application for a name/ownership change has been reviewed and is accurate and
complete to the best of my knowledge. I understand that if all required parts of this application are not
completed and that if all required supporting information is not included, this application package will be
returned as incomplete.
Signature Date
APPLICANT CERTIFICATION
I, Andre Grebenstein, attest that this application for a name/ownership change has been reviewed and is
accurate and complete to the best of my knowledge. I understand that if all required parts of this
application are not completed and that if all required supporting information is not included, this application
package will be retun incomplete.
CL�,
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Sisina re Date
PLEASE SEND THE COMPLETE APPLICATION PACKAGE TO:
Division of Energy, Mineral and Land Resources
Stormwater Permitting Program
1612 Mail Service Center
Raleigh, North Carolina 27699-1612
Revised Jan. 27, 2014