NCC205388_Contact Update Record_20211013

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Georgoulias, Bethany A 10/13/2021 8:30:52 AM (Contact Changes Submitted)

Certificate of NCC205388
Coverage (COC) Enter the Certificate of Coverage Ninber (Use capital letters)
No.*
NC Reference No. NCG01-2020-5388
Original NOI No.* 36784
Project information associated with this permit (cannot change):
Permittee Listed Organizaiton cannot be changed (new OOC required)
Public Service Company of North Carolina, Inc.
Project Name
Wendell-Knightdale Connection
Address
9820 SR 1007, Town of Knightdale, NC
County
Wake
Latitude
35.7470
Longitude
-78.4450
Date COC Issued*
11/24/2020
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This field will populate only if COChas already been rescinded.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 Shaun Randall
Individual
(Previous)

First Name (New)* Andrew
Last Name (New) * Moore
NEW Legally Peflects any revisions above
Responsible Andrew Moore
Individual*
Permittee Email [e-mail]
(Previous)
NEW Permittee [e-mail]
Email*
Permittee 704-810-3350
Telephone No.
(Previous)
NEW Permittee [phone]
Telephone No.*
Permittee Mailing P.O. Box 1398, 0, Gastonia, NC 28056-6519
Address (Previous)
NEW Permittee Street Address
Mailing Address* P.O. Box 1398
Address Line 2
City
State / Rovince / Fbgion
Gastonia
NC
Fbstal / Zip Code
Country
28053
us
Permittee Street 800 Gaston Road, Building A, Gastonia, NC
Address (Previous) 28056-6519
NEW Permittee Street Address
Street Address* 800 Gaston Road
Address Line 2
Building A
City
State / Rovince / FZegion
Gastonia
NC
Fbstal / Zip Code
Country
28056
us
Change Requested Modification request from A. Moore on 10/8/2021 and e-mail follow up from Liane
by: R. Morgan via on 10/12/2021 (provided Legally Responsible Individual Change
Form).
Include any additional correspondence records in the Fbpository CDC folder.
Additional Information for this update to contact information:
Addional
Explanation
(Optional)
Date * 10/13/2021