NCC203615_Contact Update Record (Legally Resp Change)_20210616

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Georgoulias, Bethany A 6/16/2021 2:59:01 PM (Contact Changes Submitted)

Certificate of NCC203615
Coverage (COC) Enter the Certificate of Coverage Ninber (Use capital letters)
No.*
NC Reference No. NCG01-2020-3615
Original NOI No.* 30084
Project information associated with this permit (cannot change):
Permittee Listed Organizaiton cannot be changed (new OOC required)
Calabash Station, LLC
Project Name
Calabash Station
Address
Calabash Road NW, Calabash, NC
County
Brunswick
Latitude
33.9207
Longitude
-78.5994
Date COC Issued*
08/20/2020
Prior Rescission
This field will populate only if COChas already been rescinded.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 [phone]
Telephone No. (Optional)
Legally Responsible Individual Contact Information
REVISE ONLY WHERE NECESSARY. KEEP INFORMATION THESAME IF NO CHANGES!
Legally Responsible Kerry Avant
Individual
(Previous)

First Name (New)* David
Last Name (New) * Vannoy
NEW Legally Peflects any revisions above
Responsible David Vannoy
Individual*
Permittee Email [e-mail]
(Previous)
NEW Permittee [e-mail]
Email*
Permittee 336-345-0487
Telephone No.
(Previous)
NEW Permittee [phone]
Telephone No.*
Permittee Mailing 2919 Breezevood Avenue, Suite 400, 0,
Address (Previous) Fayetteville, NC 28303-5283
NEW Permittee
Mailing Address*
Street Address
2919 Breezewood Avenue
Address Line 2
Suite 100
City
Fayetteville
Fbstal / Zip Code
28303-5283
Permittee Street 2919 Breezewood Avenue, Suite 400, 0,
Address (Previous) Fayetteville, NC 28303-5283
State / Rovince / Fbgion
NC
Country
us
NEW Permittee Street Address
Street Address* 2919 Breezewood Avenue
Address Line 2
Suite 100
city
State / Rovince / FZegion
Fayetteville
NC
Fbstal / Zip Code
Country
28303-5283
us
Change Requested David Vannoy via Modification Request submitted on 6/16/2021.
by: * Include any additional correspondence records in the Repository CciCfolder.
Additional Information for this update to contact information:
Addional
Explanation
(Optional)
Date * 06/16/2021