California Consumer CCPA Request Form

The California Consumer Privacy Act (CCPA) provides to residents of the State of California (California Consumers) the right to request to know about and/or request to delete personal information from or about them that is collected, used, and shared by Holcim Technology Ltd. (HTEC). 

Please use this form to submit your request. (Please send only one (1) form per request). Once the information provided is verified, we will do our best to fulfill your request within approximately forty-five (45) days.

Once you complete this form, you may submit it by:


  • Email to Holcim Technology Ltd. at (please indicate “CCPA California Consumer Request” in the “Subject” line) 
  • Postal mail to Holcim Technology Ltd. at 36 Iron Springs Rd, Fairfax, CA 94930, USA, Attention: Jeffrey Chen.


Once your request is received and reviewed by HTEC, in order to respond we may request from you additional information to verify the California Consumer’s/Requestor’s identity and/or qualifications to make this request. If we determine that a basis exists to deny this request, we will respond indicating our decision and an explanation of that determination. In certain instances, our response may indicate that we are not able to honor the request because a legal exemption applies that would prevent us from taking further action (e.g., a legal restriction on data deletion).  

  1. Who is the California Consumer about whom this request is being made?  

CA Consumer’s Name: ______________________________________________

Address: ______________________________________________

Email Address: ______________________________________________

  1. Are you the California Consumer whose personal information is the subject of this request? □ Yes □ No  

If “Yes,” please skip to the next question. 

If “No,” please state your name, your relationship to the California Consumer (e.g., parent/guardian/legal representative), and your contact details.  If you are submitting this form to make this request on behalf of the Consumer, please also provide documented proof that you are authorized to act on the Consumer’s behalf (e.g., proof of guardianship, power of attorney).   

Requestor’s Name: ______________________________________________

Relationship to CA Consumer: ______________________________________________

Email Address: ______________________________________________

  1. Check the box indicating the nature of the request (Choose one box per request):

Request to Know:  By checking here, you request that HTEC disclose the personal information about the above-named California Consumer that it has collected, has in its possession, and may have shared with third parties.  Please tell us more about the personal information you would like for us to provide to you.

Request to Delete:  By checking here, you request that HTEC delete all personal information about the above-named California Consumer that we have collected and used, and that we direct all third parties with whom we have shared such personal information to delete such information.


California Consumer CCPA Request Form

[Please note: the factors that we may consider in making a determination to grant or deny a request include, but are not limited to, the: (i) type(s), sensitivity and value of the personal information about which the request relates; (ii) risk of harm posed by any unauthorized access or deletion; (iii) likelihood that fraudulent or malicious actors would seek the personal information; (iv) whether the personal information to be provided to verify identity is sufficiently robust to protect against fraudulent requests or being spoofed or fabricated; (v) manner in which the business interacts with the person(s) about the whom the request relates; and (v) available technology for verification].


By submitting this request, I attest that: (1) I am either making this request on my own behalf, or I am legally authorized to act on behalf of the California Consumer identified above, and (2) to the best of my knowledge, the individual identified above as a California Consumer qualifies as a California Consumer under the CCPA.  


Signature of Requestor: _____________________________________________   


Date: _______________________________