NCG060378_Name-Owner Change Form_5/22/2019

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 5/22/2019 12:02:33 PM (Name Change Submission)
Approve by McCoy, Suzanne 6/11/2019 8:32:35 AM (Notification to Admin)
• The task was assigned to McCoy, Suzanne 5/22/2019 12:02 PM

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I. Permit Information
I. Please enter the permit number for which the change is requested.
NPDES Stormwater Individual Permit #:
NC
SX
XX
XX
X
-OR-
General Permit Certificate of Coverage (COC) #:
NCG060378
NC
GX
XX
XX
X
Use this link to check the permit contact information that is currently in our database.

II. Permit Status
11. Permit status prior to requested change.
a. Permit issued to: Revlon Consumer Products
Conpany %rre
b. Person legally responsible for permit:
First name:* Middle name: Last name:*
David Hamilton
Title: VP Manufacturing and Plant Manager
Permit holder's mailing address:*
Phone #:*
91960
32216
c. Facility name:*
d. Facility address:*
Fax #:
91960
32270
Street Address
1501 Williamsboro Street
Address Line 2
aty State / Rovince / Pegion
Oxford North Carolina
Fbstal / Zip Code Country
27565 United States
Revlon Consumer Products
Street Address
1501 Williamsboro Street
Address Line 2
aty State / Rovince / Fbgion
Oxford North Carolina
Fbstal / Zip Code Country
27565 United States
e. Facility contact person (prior to change, optional):
First name: Middle name: Last name:
Mayumi Lawson
Phone #: [phone]

III. Requested Change Information
111. Please provide the following for the requested change (revised permit).
a. Request for changes is a result r Change in ownership of facility
of: * r Name Change of the facility or owner
b. Permit to be issued to: Revlon Consumer Products
Conpany %ne
c. Person to be legally responsible for permit:
First name:* Middle name: Last name:*
Maurice York
Title: VP - Mfg & Facility Mgr. Oxford
Permit holder's mailing address:*
Street Address
1501 Williamsboro Street
Address Line 2
aty
Oxford
Wstal / Zip Code
27565
Phone #:* Email address:*
91960 maurice.
32027 york@re
vlon.com
d. Faciltiy name:* Revlon Consumer Products
Is the FACILITY contact different than the person legally responsible
above?*
r Yes
f No
f. Facility contact person:
First name:*
Mayu mi
Phone #:*
Middle name
9196032305
Email address:* [e-mail]
Last name:*
Lawson
State / Frovince / Plegion
North Carolina
Country
United States

IV. Permit Contact Information
Is the PERMIT contact different than the person legally responsible
above?
r Yes
r No
IV. Permit contact information
(if different form the person legally responsible for the permt)
............................................................................................................................................................................
First Name:*
Middle Last Name:*
Mayumi
Name: Lawson
Title:
EHS Engineer
Mailing Address:*
Street Address
1501 Williamsboro Street
Address Line 2
aty
Oxford
Fbstal / Zip Code
27565
Phone #:* 9196032305
Email Address:* [e-mail]
State / Rovince / Fbgion
North Carolina
Country
United States

V. Permit Facility Activities
V. Will the permitted facility continue to conduct the SAME industrial activities conducted prior to this
ownership or name change:*
r Yes
r No

VI. Signature
In the case of an ownership change request, certifications must be signed by both the permit holder
prior to the change and the new applicant. For a name change request, the signed Permittee's
Certification is sufficient.
This completed application is required for both name change and/or ownership change requests.
North Carolina General Statute 143 - 215.6 b (i) provides that:
Any person who knowingly makes any false statement, representation, or certification in any application, record, report, plan, or
other document filed or required to be maintained under this Article or a rule implementing this Article; or who knowingly makes a
false statement of a material fact in a rulemaking proceeding or contested case under this Article; or who falsifies, tampers with, or
knowingly renders inaccurate any recording or monitoring device or method required to be operated or maintained under this Article
or rules of the [Environmental Management] Commission implementing this Article shall be guilty of a Class 2 misdemeanor which
may include a fine not to exceed ten thousand dollars ($10,000).
Permittee Certification: I attest that this application for a name and/or 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, or if all required supporting information is not included, this application will be considered incomplete.
Permittee Signature
Fbrrrit-holder prior to the ownership change, or permt-holder authorizing the narre change
Will another person need to complete or sign this form before it can be submitted? No problem! Simply CLICK
the "Save as Draft" button below and send the URL link to the other party to access the form. Questions? Call The
Stormwater Program at [phone] or e-mail Annette Lucas at annette.lucaslcDncdenr.gov.

Initial Review
Project ID: * Fbviewer may revise perrrit number here if incorrect.
NCG060378