HomeMy WebLinkAboutNCC191946_Contact Update Record_20240920 Action History (UTC-05:00)Eastern Time(US&Canada)
Submit by bethany.georgoulias 9/20/2024 4:09:52 PM (Contact Changes Submitted)
Contact • - for • • • ONLY)
updatesThis form • . .
Certificate of NCC191946
Coverage(COC) No.* Enter the Certificate of Coverage Number(Use capital letters)
NC Reference No. NCG01-2019-1946
Original NOI No.* 15967
Project information associated with this permit(cannot change):
Permittee Listed Organizaiton cannot be changed(new COC required)
Marshallberg Voluntary Fire Department, Inc.
Project Name Marshallberg Voluntary Fire Department
Address 1138 Straits Road,Smyrna, NC
County Carteret
Latitude 34.7470
Longitude -76.5211
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Prior Rescission Date This field will populate only if COC has already been rescinded.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? Q No
Yes
Billing Email
NEW Billing Email twade5916@gmail.com
Billing Telephone No.
NEW Billing (252)241-0733
Telephone No. (Optional)
Legally Responsible Individual Contact Information
REVISE ONLY WHERE NECESSARY. KEEP INFORMATION THESAME IF NO CHANGES!
Legally Responsible John Day
Individual(Previous)
First Name(New)* Rodney Todd
Last Name(New)* Wade
NEW Legally Reflects any revisions above
Responsible Rodney Todd Wade
Individual*
Permittee Email johnday.nc@gmail.com
(Previous)
NEW Permittee twade5916@gmail.com
Email*
Permittee Telephone 252-729-5111
No.(Previous)
NEW Permittee (252)241-0733
Telephone No.*
Permittee Mailing P.O. Box 6, 0, Marshallberg, NC 28579-9541
Address(Previous)
NEW Permittee Street Address
Mailing Address* P.O. Box 6
Address Line 2
City State/Province/Region
Marshallberg NC
Postal/Zip Code Country
28553 us
Permittee Street 1138 Straits Road,0,Smyrna, NC 28579-
Address(Previous) 9541
NEW Permittee Street Street Address
Address* 109 Goose Pond Rd
Address Line 2
City State/Province/Region
Marshallberg NC
Postal/Zip Code Country
28553 us
Change Requested Jeffrey Leland Batten(Board of Directors Treasurer)via Modification request
by:* submitted 9/17/2024.
Include any additional correspondence records in the Repository COC folder.
Additional Information for this update to contact information:
Addional Explanation
(Optional)
Date* 09/20/2024