NCS000057_Owner Affiliation Change_20221209

Division of Energy, Mineral, and Land Resources
c+ Land Quality Section I Stormwater Program
t. lti
National Pollutant Discharge Elimination System (NPDES)
Energy. Mineral & PERMIT OWNER AFFILIATION DESIGNATION FORM
Lund Resources ENVltlONH[N7ALaUA7.RY (individual Legally Responsible for Permit)
Use this form if there has been:
FOR AGENCY USE ONLY
Pate ReccEVsd
Yessr
I Mouth .
Du
s ai LTAr r.
if the am of the facility has changed, ar if the ownersh►a of the facility has changed,
do NOT use this form. Instead, you roust rill out a Name -Ownership Change Form
and submit the completed form with all required documentation.
Whitt 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 (ot) Certificate of Coverage or No Exposure
f N C 5 0 0 D 0 5 7 N. C LG.'
2) Facility Information,
Facility name: Venator Chemicals LLC
Company/Owner Organization: Venator Chemicals LLC
Facility address: 5910 Pharr Mill Road _. .
Address
Harrisburg NC 28075
City State Zip
To find the current legally responsible person associated with your permit, go to this website:
lilt s:i/dt .nc, pi+/alnufldtvtsait.s�enet tnnertil-land•resources/ever-ininell=l7ricl� eriitc/n idesndustil-
program and run the Permit Contact Summary Report.
3) 21& OWNER AFFILIATION that should be remQvedr
Previous legally responsible individual: Timothy Smart
First MI Last
4) SEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit:
Timothy Smart
First lvtt Lnst
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5 WU-OWNERAFF1L4Nov2019

NPDIS Stormwater Permit OWNER AFFILIATION DESIGNATION
Form (if no Facility Name/Ownership Change)
North American Manufacturing Director
Title
5910 Pharr Mill Road
Mailitig Address
Harrisburg NC 28076
City State Zip
(704 } 455-5181 tim [e-mail]
Telephone E-mail Address
(704 )455-6507
Fax Number
5) Reason for this change:
A result of: 0 Employee or management change
Inappropriate or incorrect designation before
Q Other
If'other please explain: Incorrect mailing and cunt@ct Information
............... .....,.................. ...............,..: .........................
The certification below must be completed and signed by the permit holder.
PERMITTEE CERTIFICATION;.
1, Tim Smart , 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
processed.
12/15/2022
Signature Date
PLEASE SEND THE COMPLETED FORM TO:
DEMLR - Storinwater 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: littp;//deq nc.goy/about/divisions/energy-mineral-lalid-resources/stormwater.
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swu-owNgaA FlL,4Nov2n19