NCG210281_Name-Owner Change Form_6/29/2018 (2)

Environmental
Quakry
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) #:
NCG210281
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: CMH Manufacturing, Inc. d/b/a Schult Homes - Plant
908
Companyfbrre
b. Person legally responsible for permit:
First name:* Middle name: Last name:*
Marty Bostrom
Title:
Permit holder's mailing address:*
Street Address
P.O. Box 9780
Address Line 2
City
State / Province / Fbgion
Maryville
Tennessee
Fbstal / Zip Code
Country
37082
Blount
Phone #: * Fax #:
865-
380-
3000
c. Facility name:*
CMH Manufacturing, Inc.
D/B/A Schult Homes - Plant
908
d. Facility address:*
Street Address
1 Viscount Ave
Address Line 2
P.O. Box 700
aty
State / Province / Fbgion
Rockwell
North Carolina
Postal / Zip Code
Country
28138
Rowan
e. Facility contact person (prior to change, optional):
First name: Middle name: Last name:
Jody Kirkman
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: CMH Manufacturing, Inc. dba Schult Homes - Rockwell
Frame Shop
Company Name
c. Person to be legally responsible for permit:
First name:* Middle name: Last name:*
Joe Earnhard
t
Title: General Manager
Permit holder's mailing address:* Street Address
1 Viscount Road
Address Line 2
d. Faciltiy name:* Schult Homes - Rockwell Frame Shop
Is the FACILITY contact different than the person legally responsible
above?*
r Yes
r No
f. Facility contact person:
First name:* Middle name: Last name:*
Eben Snow
Phone #:* 7042794659
Email address:* [e-mail]
City
State / Rovince / Pegion
Rockwell
NC
Wstal / Zip Code
Country
28138
us
Phone #:* Email address:*
70427 joe.earnh
94659 ardt@sc
hulthome
s.com
d. Faciltiy name:* Schult Homes - Rockwell Frame Shop
Is the FACILITY contact different than the person legally responsible
above?*
r Yes
r No
f. Facility contact person:
First name:* Middle name: Last name:*
Eben Snow
Phone #:* 7042794659
Email address:* [e-mail]

IV. Permit Contact Information
Is the PERMIT contact different than the person legally responsible
above?*
f• Yes
r No
IV. Permit contact information
(if different form the person legally responsible for the permt)
....................................................................................................................................................................................................
First Name:* Middle Last Name:*
Eben Name: Snow
Title:
Mailing Address:* Street Address
1 Viscount Road
Address Line 2
City
Rockwell
F bstal / Zip Code
28138
Phone #:* 7042794659
Email Address:* [e-mail]
State / Province / Fbgion
North Carolina
Country
Rowan

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
FLrrrit-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 Laura
Alexander at [phone] or e-mail her at [e-mail].

Initial Review
Project ID:* NCG210281