NCGNE1204_Owner Affiliation Change_20240510

Division of Energy, Mineral, and Land Resources FOR AGENCY USE ONLY
Land Quality Section /Stormwater Program Date Received
Q tyro g Year Month Day
'Kr National Pollutant Discharge Elimination System (NPDES)
PERMIT OWNER AFFILIATION DESIGNATION FORM
(Individual Legally Responsible for Permit)
Use this form if there has been:
NO CHANGE in facility ownership or facility name, but the individual
who is legally responsible for the permit has changed.
If the name of the facility has changed, or if the ownership of the facility has changed,
do NOT use this form. Instead, you must fill out a Name-Ownership Change Form
and submit the completed form with all required documentation.
What 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 (or) Certificate of Coverage or No Exposure
N C S NC G 0 3 0 5 9 2
2) Facility Information:
Facility name: Collins Aerospace Customer Service
Company:Owner Organization:
Facility address: 4115 Corporate Center Drive
Address
Monroe NC 28110
City State Zip
To find the current legally responsible person associated with your permit,go to this website:
Imps: dj di\',Ion, :ncr�Lt\-mineral-land resources energ\ mineral land permits npdes-industrial
prow-ant and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: Mary DeStaffan
First MI Last
4) NEW OWNER AFFILIATION(legally responsible for the permit):
Person legally responsible for this permit: Haywood Stowe
First MI Last
Page 1 of 2
S WU-OWNERAFFQANov20l9

NPDES Stormwater Permit OWNER AFFILIATION DESIGNATION
Form (if no Facility Name/Ownership Change)
General Manager
- - -------- 'rifle
4115 Corporate Center Drive
\feilin�AddreNs
Monroe NC 28110
('its State Zip
t ) [e-mail]
•
Telephone li at.til Address
:IX Number
5) Reason for this change:
A
result of: [] Ltrtplovice or management change
0 Inappropriate or Incorrect designation before
❑ Other
11 other please evphtin:
The certification below must be completed and signed by the permit holder.
PERiIIT'1'EE CERTIFICATION:
Haywood G. Stowe III —_�,attest that this application I'>r this change in Owner Affiliation
(person legally responsible i,r the permit)has been re%iewed and is .tccurate 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 he
processed.
1U -2. Li
Sicnature Date
PLEASE SEND THE COMPLETED FORM TO:
DE-\•1LR- Stormwater Program
Dept. of Environmental Quality
1612 Mail I Service Center
Raicigh, North Carolina 27699-1612
For more information in stall contacts. please call [phone]()or visit the website
at: httr: dec(.ttc.<<o about diti.ions'eltergw-mineral-land-resc,urces statlttllater
`ICI'-O5CXritt 1t 1'It.--I\,.‘',ii')