NCGNE1203_Owner Affiliation Change_20210505

Division of Energy, Mineral, and Land Resources
Land Quality Section / Stormwater Program
National Pollutant Discharge Elimination System (NPDES)
Energy. Mineral & PERMIT OWNER AFFILIATION DESIGNATION FORM
Land Resources
ENVIRONMENTAL QUALITY (Individual Lanaliv RpAnnncihlp fnr Parmifl
FOR AGENCY USE ONLY
Date Received
Year
I Month
Day
Use this form if there has been: a
NO CHANGE in facility ownership or facility name, but the " dividua1
who is legally responsible for the permit has cha DR -LAND QUALITY
I VATER PERMITTING
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);
0 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
N I C I S 2 1 0 10 10 101
2) Facility Information:
Facility name:
Company/Owner Organization
Facility address:
(or) Certificate of Coverage or No Exposure
N C G 2-1 110 12 10
Champion Home Builders
Skyline Champion
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:Hdeg.nc.gov/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
First
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit: Jason
E. Johnson
MI Last
M. Norris
MI Last
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NPDES Stormwater Permit OWNER AFFILIATION DESIGNATION
Form (if no Facility Name/Ownership Change)
General Manager
Title
4055 US 401 South
Mailing Address
Lillington, NC 27546
City State Zip
( 910 ) 893-5713 [e-mail]
Telephone E-mail Address
r 910 1814-0946
Fax Number
5) Reason for this change:
A result of: 0 Employee or management change
0 Inappropriate or incorrect designation before
❑ Other
If 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
processed.
k
i
1 Signatu e
30 April 2021
PLEASE SEND THE COMPLETED FORM TO:
DEMLR - Stormwater Program
Dept. of Environmental Quality
1612 Mail Service Center
Raleigh, North Carolina 27699-1.612
Date
For more information or staff contacts, please call [phone] or visit the website
at: http://deg.nc.gov/about/divisions/energy-mineral-land-resources/stormwater
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