NCGNE1204_Name-Owner Change Form_5/30/2019

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Anonymous User 5/30/2019 2:41:43 PM (Name Change Submission)
Approve by McCoy, Suzanne 6/11/2019 9:26:54 AM (Notification to Admin)
• The task was assigned to McCoy, Suzanne 5/30/2019 2:41 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) #:
NCGNE1204
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: Goodrich Corporation
Corrpany %rre
b. Person legally responsible for permit:
First name:* Middle name: Last name:*
Mike Van
Title:
Permit holder's mailing address:*
Phone #:*
704 704
282- 282-
2535 2581
c. Facility name:*
d. Facility address:*
Fax #:
Wingerd
en
General Manager
Street Address
4115 Corporate Center Drive
Address Line 2
oty
Monroe
Fbstal / Zip Code
28110
State / Province / Region
NC
Country
USA
LTC Aerospace Systems Customer Service
Street Address
4115 Corporate Center Drive
Address Line 2
oty
Monroe
Postal / Zip Code
28110
e. Facility contact person (prior to change, optional):
First name: Middle name: Last name:
Andrew Boulange
r
Phone #: [phone]
State / Province / Region
NC
Country
USA

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: Goodrich Corporation
Conpany %ne
c. Person to be legally responsible for permit:
First name:* Middle name: Last name:*
Vida Butler
Title: General Manager
Permit holder's mailing address:*
Street Address
4115 Corporate Center Drive
Address Line 2
Oty
Monroe
Rxstal / Zip Code
28110
Phone #:* Email address:*
704 vida.butl
282- er@collin
2702 s.com
d. Faciltiy name:* Collins Aeropsace
Is the FACILITY contact different than the person legally responsible
above?*
r Yes
f No
f. Facility contact person:
First name:*
Andrew
Phone #:*
Middle name
704 282-2590
Last name:*
Boulange
r
Email address:* [e-mail]
State / Rovince / Plegion
NC
Country
USA

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:*
Andrew Name: Boulange
r
Title: EH&S Manager
Mailing Address:* Street Address
4115 Corporate Center Drive
Address Line 2
City
Monroe
F bstal / Zip Code
28110
Phone #:* 704 282-2590
Email Address:* [e-mail]
State / Province / Fbgion
NC
Country
USA

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 (1) 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
IV
FLrrrit-holder prior to the ownership change, or permt-hdder authorizing the narre change
Will another person need to complete or sign this form before it can be submitted? 11/o 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.lucas(a)ncdenr.gov.

Initial Review
Project ID: * Fbviewer may revise perrrit number here i incorrect.
NCGNE1204