NCC200776_Contact Update Record_20240205

Action History (UTC-05:00)Eastern Time(US&Canada)
Submit by bethany.georgoulias 2/5/2024 4:29:56 PM(Contact Changes Submitted)

Contact • - for • • • ONLY)
updatesThis form • . .
Certificate of NCC200776
Coverage(COC) No.* Enter the Certificate of Coverage Number(Use capital letters)
NC Reference No. NCG01-2020-0776
Original NOI No.* 22441
Project information associated with this permit(cannot change):
Permittee Listed Organizaiton cannot be changed(new COC required)
Vineyards Management Group
Project Name Creekside Mobile Home Park
Address 400 Stoney Creek Dr, Reidsville, NC
County Rockingham
Latitude 36.3390
Longitude -79.6330
Date COC Issued* 03/06/2020
Prior Rescission Date This field will populate only if COC has already been rescinded.
Which Contacts Have Billing Only
Changed?* Legally Responsible Individual Only
Site Contact Only
BOTH Legally Responsible Individual and Site Contact
Has Billing Contact Choose'Yes'to revise Billing Contact details.
Changed? Q No
�i Yes
Billing Email
NEW Billing Email [e-mail]
Billing Telephone No.
NEW Billing [phone]
Telephone No. (Optional)
Legally Responsible Individual Contact Information
REVISE ONLY WHERE NECESSARY. KEEP INFORMATION THESAME IF NO CHANGES!
Legally Responsible Chad Astle
Individual(Previous)
First Name(New)* Donald Thomas
Last Name(New)* Stapley

NEW Legally Reflects any revisions above
Responsible Donald Thomas Stapley
Individual*
Permittee Email [e-mail]
(Previous)
NEW Permittee [e-mail]
Email*
Permittee Telephone [phone]
No.(Previous)
NEW Permittee [phone]
Telephone No.*
Permittee Mailing 1371 East 2100 South,0,Salt Lake City, LIT
Address(Previous) 84105
NEW Permittee Street Address
Mailing Address* 400 Stoney Creek Drive
Address Line 2
City State/Province/Region
Reidsville NC
Postal/Zip Code Country
27320 us
Permittee Street 1371 East 2100 South,0,Salt Lake City, LIT
Address(Previous) 84105
NEW Permittee Street Street Address
Address* 400 Stoney Creek Drive
Address Line 2
City State/Province/Region
Reidsville NC
Postal/Zip Code Country
84105 us
Change Requested Shalonda Lotharp and Tina Graska via email on 1/30/2024
by:* Include any additional correspondence records in the Repository COC folder.
Additional Information for this update to contact information:
Addional Explanation
(Optional)
Date* 02/05/2024