NCG210202_Owner Affiliation Change_20211018

Division of Energy, Mineral, and Land Resources
Land Quality Section / Stormwater Program
K_ r1a National Pollutant Discharge Elimination System (NPDES)
FOR AGENCY USE ONLY
Date Received
Year
I Month
I Day
Energy, Mineral & PERMIT OWNER AFFILIATION DESIGNATION FORM`{= �'
Land Resources
ED
ENVIRONMENTAL QUALITY (Individual Legally Responsible for Permit)
t 51
Use this form if there has been: L'ENR-LAND OUAI I`?Y
NO CHANGE in facility ownership or facility name, but the indEVPdU9WERPERN!TTih
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 rill 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 I C I S I I I N I C I G 12 1 0 2 0 2
2) Facility Information:
Facility name: Champion Home Builders Inc.
Company/Owner Organization: Skyline Champion
Facility address: 4055 US 401 South
Address
Lillington_ NC 27546
City State Zip
To find the current legally responsible person associated with your permit, go to this website:
https://deg.nc.goy/about/divisions/energy-mineral-land-resources/energy-mineral-land-permits/npdes-industrial-
rp ogram and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: James E. Johnson
First MI Last
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit: Jason M. Norris
First MI Last
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NPDES Stormwater Permit OWNER AFFILIATION DESIGNATION
Form (if no Faeility Name/Ownership Change)
General Manager
Title
4055 US Hwy 401 South
Mailing Address
Lillington NC 27546
City State Zip
(910 )893-5713 [e-mail]
Telephone E-mail Address
(910 ) 893-5087
Fax Number
5) Reason for this change:
❑✓ Employee or management change
A result of: ❑ Inappropriate or incorrect designation before
❑ Other
lf other please explain:
The certification below must be completed and signed by the permit holder.
PERMITTEE CERTIFICATION:
1 Jason M. Norris , 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
12 November 2021
Date
PLEASE SEND THE COMPLETED FORM TO:
DEMLR - Stormwater 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: http://deg.ne.gov/about/divisions/energy-mineral-land-resources/stotmwater
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S WU-O WNERAFFIL-4Nov20l9