NCC215360_Contact Update Record_20231005

Action History (UTC-05:00)Eastern Time(US&Canada)
Submit by Tev.Holloman 10/5/2023 12:54:43 PM (Contact Changes Submitted)

Contact • - for • • • ONLY)
updatesThis form • . .
Certificate of NCC215360
Coverage(COC) No.* Enter the Certificate of Coverage Number(Use capital letters)
NC Reference No. NCG01-2021-5360
Original NOI No.* 66566
Project information associated with this permit(cannot change):
Permittee Listed Organizaiton cannot be changed(new COC required)
Front Street-Wallburg,LLC
Project Name Front Street-Wallburg, LLC Wallburg Road-Pump Station
Address Wallburg Road,Winston-Salem, NC
County Forsyth
Latitude 36.0395
Longitude -80.1348
Date COC Issued* 09/29/2021
Prior Rescission Date This field will populate only if COC has already been rescinded.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
0 Yes
Billing Email [e-mail]
NEW Billing Email [e-mail]
Billing Telephone No. 336-243-2600
NEW Billing 336-243-2600
Telephone No. (Optional)
Site Contact Information
REVISE ONLY WHERE NECESSARY. KEEP INFORMATION THESAME IF NO CHANGES!
Site Contact Robin Team
(Previous)
Site Contact Title Manager
(Previous)

Organization Front Street-Wallburg, LLC
(Previous)
First Name(New)* Jonathan
Last Name(New)* Starnes
NEW Site Contact* Reflects any revisions above
Jonathan Starnes
NEW Site Contact Partner
Title
NEW Organization Front Street-Wallburg, LLC
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 336-243-2600
Telephone No.
(Previous)
NEW Site Contact 336-243-2600
Telephone No.*
Site Contact Mailing 450 North Patterson Avenue,Suite 300,0,
Address(Previous) Winston-Salem, NC 27101
NEW Site Contact Street Address
Mailing Address* 450 North Patterson Avenue,Suite 300
Address Line 2
City State/Province/Region
Winston-Salem NC
Postal/Zip Code Country
27101 us
Change Requested Jonathan Starnes, Partner,via email on 10/4/2023
by:* Include any additional correspondence records in the Repository COC folder.
Additional Information for this update to contact information:
Addional Explanation
(Optional)
Date* 10/05/2023