NCC230011_Contact Update Record (Site Contact)_20230320

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by bethany.georgoulias 3/20/2023 1:15:50 PM (Contact Changes Submitted)

Certificate of
NCC230011
Coverage (COC) No.*
Enter the Certificate of Coverage Number (Use capital letters)
NC Reference No.
NCG01-2023-0011
Original NOI No.*
121170
Project information associated with this permit (cannot change):
Permittee Listed Organizaiton cannot be changed (new COC required)
LeoTerra Hanes Mill Storage, LLC
Project Name Hanes Mill Storage
Address 381 E Hanes Mill Rd, Winston-Salem, NC
County Forsyth
Latitude 36.1883
Longitude-80.2704
Date COC Issued* 01/11/2023
Prior Rescission Date This field will populate only if COC has already been rescinded.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
n Yes
Billing Email
[e-mail]
NEW Billing Email
[e-mail]
Billing Telephone No.
336-967-6260
NEW Billing
[phone]
Telephone No.
(Optional)
Legally Responsible Individual Contact Information
REVISE ONLY WHERE NECESSARY. KEEP INFORMATION THESAME IF NO CHANGES!
Legally Responsible Christopher Lyons
Individual (Previous)
First Name (New)* Christopher
Last Name (New) * Lyons

NEW Legally Reflects any revisions above
Responsible Christopher Lyons
Individual*
Permittee Email [e-mail]
(Previous)
NEW Permittee [e-mail]
Email*
Permittee Telephone [phone]
No. (Previous)
NEW Permittee [phone]
Telephone No.*
Permittee Mailing 110 Shields Park Dr, 0, Kernersville, NC
Address (Previous) 27284-3567
NEW Permittee Street Address
Mailing Address* 110 Shields Park Dr
Address Line 2
City
State / Province / Region
Kernersville
NC
Postal / Zip Code
Country
27284-3567
us
Permittee Street 110 Shields Park Dr, 0, Kernersville, NC
Address (Previous) 27284-3567
NEW Permittee Street Street Address
Address* 110 Shields Park Dr
Address Line 2
City
State / Province / Region
Kernersville
NC
Postal / Zip Code
Country
27284-3567
us
Site Contact Information
REVISE ONLY WHERE NECESSARY. KEEP INFORMATION THESAME IF NO CHANGES!
Site Contact Christopher Lyons
(Previous)
Site Contact Title Manager
(Previous)
Organization LeoTerra
(Previous)
First Name (New)* Kat
Last Name (New) * Lyons
NEW Site Contact* Reflects any revisions above
Kat Lyons

NEW Site Contact Senior Director of Entitlements
Title
NEW Organization LeoTerra Development Inc.
This field is not required on the NOI form and may not pre -populate.
Site Contact Email [e-mail]
(Previous)
NEW Site Contact [e-mail]
Email*
Site Contact 336-967-6260
Telephone No.
(Previous)
NEW Site Contact [phone]
Telephone No.*
Site Contact Mailing 110-A Shields Park Dr, 0, Kernersville, NC
Address (Previous) 27284
NEW Site Contact Street Address
Mailing Address* 110-A Shields Park Dr
Address Line 2
City
State / Province / Region
Kernersville
NC
Postal / Zip Code
Country
27284
us
Change Requested Jason Cheek via email requesting site contact updates on 3/10/2023. Email for
by: * current legally responsible individual updated.
Include any additional correspondence records in the Repository COC folder.
Additional Information for this update to contact information:
Addional Explanation
(Optional)
Date * 03/20/2023