NCC222324_Contact Update Record_20240604

Action History (UTC-05:00)Eastern Time(US&Canada)
Submit by bethany.georgoulias 6/4/2024 1:17:49 PM(Contact Changes Submitted)

Contact • - for • • • ONLY)
updatesThis form • . .
Certificate of NCC222324
Coverage(COC) No.* Enter the Certificate of Coverage Number(Use capital letters)
NC Reference No. NCG01-2022-2324
Original NOI No.* 94836
Project information associated with this permit(cannot change):
Permittee Listed Organizaiton cannot be changed(new COC required)
Jimmy R. Drake
Project Name Calloway Property: Rodeo Site
Address 3520 Saint James Church Road, Denver, NC
County Lincoln
Latitude 35.5272
Longitude -81.0263
Date COC Issued* 04/01/2024
Prior Rescission Date This field will populate only if COC has already been rescinded.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? No
Yes
Billing Email [e-mail]
NEW Billing Email [e-mail]
Billing Telephone No. 828-713-3006
NEW Billing [phone]
Telephone No. (Optional)
Legally Responsible Individual Contact Information
REVISE ONLY WHERE NECESSARY. KEEP INFORMATION THESAME IF NO CHANGES!
Legally Responsible Jimmy Drake
Individual(Previous)
First Name(New)* Jimmy
Last Name(New)* Drake

NEW Legally Reflects any revisions above
Responsible Jimmy Drake
Individual*
Permittee Email [e-mail]
(Previous)
NEW Permittee [e-mail]
Email*
Permittee Telephone [phone]
No.(Previous)
NEW Permittee [phone]
Telephone No.*
Permittee Mailing 612 3rd St PI SW,0, Conover, NC 28613-
Address(Previous) 2622
NEW Permittee Street Address
Mailing Address* 612 3rd St PI SW
Address Line 2
City State/Province/Region
Conover NC
Postal/Zip Code Country
28613-2622 us
Permittee Street 612 3rd St PI SW,0, Conover, NC 28613-
Address(Previous) 2622
NEW Permittee Street Street Address
Address* 612 3rd St PI SW
Address Line 2
City State/Province/Region
Conover NC
Postal/Zip Code Country
28613-2622 us
Site Contact Information
REVISE ONLY WHERE NECESSARY. KEEP INFORMATION THESAME IF NO CHANGES!
Site Contact Jimmy Drake
(Previous)
Site Contact Title Property Lease Holder
(Previous)
Organization
(Previous)
First Name(New)* Jimmy
Last Name(New)* Drake
NEW Site Contact* Reflects any revisions above
Jimmy Drake

NEW Site Contact Property Lease Holder
Title
NEW Organization 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 828-713-3006
Telephone No.
(Previous)
NEW Site Contact [phone]
Telephone No.*
Site Contact Mailing 612 3rd St PI SW,0, Conover, NC 28613-
Address(Previous) 2622
NEW Site Contact Street Address
Mailing Address* 612 3rd St PI SW
Address Line 2
City State/Province/Region
Conover NC
Postal/Zip Code Country
28613-2622 us
Change Requested Stefania Arrieta via email on 6/2/2024. Email address update only(prior one will not
by:* be valid at the end of the month.)Billing contact updated to include Ms.Arrieta's
phone number as an additional point of contact.
Include any additional correspondence records in the Repository COC folder.
Additional Information for this update to contact information:
Addional Explanation
(Optional)
Date* 06/04/2024