NCGNE0967_Name-Owner Change Form_5/14/2019

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 5/14/2019 1:51:25 PM (Name Change Submission)
Approve by McCoy, Suzanne 6/10/2019 2:52:25 PM (Notification to Admin)
* Facility address is 500 Radar Road units 1- M.
• The task was assigned to McCoy, Suzanne 5/14/2019 1:51 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) #:
NCG NE0967
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: HAECO Americas Airframe Services
Conpany farce
b. Person legally responsible for permit:
First name:* Middle name: Last name:*
Robert Nelson
Title:
Permit holder's mailing address:* Street Address
623 Radar Road ATTN: Brett Houser
Address Line 2
aty State / Province / Fbgion
Greensboro NC
Fbstal / Zip Code Country
27410 United States
Phone #:* Fax #:
33666 33666
84410 59009
32050
c. Facility name:* HAECO Americas
d. Facility address:* Street Address
623 Radar Road ATTN: Brett Houser
Address Line 2
aty State / Province / Fbgion
Greensboro NC
Fbstal / Zip Code Country
27410 United States
e. Facility contact person (prior to change, optional):
First name: Middle name: Last name:
Robert Nelson
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: HAECO Americas Airframe Services
Corrpany Nacre
c. Person to be legally responsible for permit:
First name:* Middle name: Last name:*
Robert Nelson
Title: General Manager
Permit holder's mailing address:* Street Address
623 Radar Road ATTN: Brett Houser
Address Line 2
Oty State / Province / Fbgion
Greensboro NC
Wstal / Zip Code Country
27410 United States
Phone #:* Email address:*
33666 Jennifer.
84410 Snider@
haeco.ae
ro
d. Faciltiy name:* HAECO Americas
Is the FACILITY contact different than the person legally responsible
above?*
r Yes
f No
f. Facility contact person:
First name:*
Nathana
el
Phone #:*
Middle name:
3366684410
Email address:* nathan.reed @haeco.aero
Last name:*
Reed

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 perrrit)
...................................................................................................................................................................................................................
First Name:* Middle Last Name:*
Robert Name: Nelson
Title: Environmental Manager
Mailing Address:* Street Address
623 Radar Road ATTN: Brett Houser
Address Line 2
aty State / Rovince / Fbgion
Greensboro NC
F bstal / Zip Code Country
27410 United States
Phone #:* 3366684410
Email Address:* [e-mail]

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
Wat 10a
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.
NCGNE0967