NCC193123_Contact Update Record_20201218

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Georgoulias, Bethany 12/18/2020 3:54:09 PM (Contact Changes Submitted)

Certificate of NCC193123
Coverage (COC) Enter the Certificate of Coverage Ninber (Use capital letters)
No.*
NC Reference No. NCG01-2019-3123
Original NOI No.* 19163
Project information associated with this permit (cannot change):
Permittee Listed Organizaiton cannot be changed (new OOC required)
MCAS Cherry Point
Project Name
Repair Asphalt Parking Lot building 3919
Address
Range Road, Havelock/Cherry Point, NC
County
Craven
Latitude
34.9136
Longitude
-76.8787
Date COC Issued*
12/11/2019
Prior Rescission
This field will populate only if OOChas already been rescinded.
Date
Which Contacts
f Billing Only
Have Changed?*
F Legally Responsible Individual Only
f Site Contact Only
r BOTH Legally Responsible Individual and Site Contact
Has Billing Contact
Choose'Yes'torevise Billing Contact details.
Changed?
r No
r Yes
Billing Email
NEW Billing Email* [e-mail]
Billing Telephone
No.
NEW Billing 252-466-3807
Telephone No. (Optional)
Legally Responsible Individual Contact Information
REVISE ONLY WHERE NECESSARY. KEEP INFORMATION THESAME IF NO CHANGES!
Legally Responsible Charles Schulz
Individual
(Previous)

First Name (New)* Anthony
Last Name (New) * Ference
NEW Legally Peflects any revisions above
Responsible Anthony Ference
Individual*
Permittee Email [e-mail]
(Previous)
NEW Permittee [e-mail]
Email*
Permittee
2524663148
Telephone No.
(Previous)
NEW Permittee
252-466-3807
Telephone No.*
Permittee Mailing
P.O Box8006, 0, Cherry Point, NC 28533-
Address (Previous)
0006
NEW Permittee
Mailing Address*
Street Address
P.O Box 8006
Address Line 2
Cly
Cherry Point
Fbstal / Zip Code
28533-0006
Permittee Street Building 1 C Street, 0, Cherry Point, NC
Address (Previous) 28533-0006
NEW Permittee
Street Address*
Street Address
Building 1 C Street
Address Line 2
city
Cherry Point
Fbstal / Zip Code
28533-0006
State / Rovince / Fbgion
NC
Country
United States
State / province / FZegion
NC
Country
United States
Change Requested Anthony Ference via Modification request on 12/18/2020.
by: * Include any additional correspondence records in the Pepository CDC folder.
Additional Information for this update to contact information:
Addional Populated billing contact with legally responsible person info.
Explanation
(Optional)
Date * 12/18/2020