NCC204915_Contact Update Record (Legally Resp Change)_20220627

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Georgoulias, Bethany A 6/27/2022 9:15:45 PM (Contact Changes Submitted)

Certificate of NCC204915
Coverage (COC) No.* Enter the Certificate of Coverage Number (Use capital letters)
NC Reference No. NCG01-2020-4915
Original NOI No.* 34489
Project information associated with this permit (cannot change):
Permittee Listed Organizaiton cannot be changed (new COC required)
Dominion Energy of North Carolina, Inc.
Project Name NC-55 8-In. Connection
Address NC-55, Cary, NC
County Wake
Latitude 35.8220
Longitude-78.8740
Date COC Issued * 10/30/2020
Prior Rescission Date This field will populate only if COC has already been rescinded.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? U No
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 Reflects any revisions above
Responsible Andrew Moore
Individual*
Permittee Email [e-mail]
(Previous)
NEW Permittee [e-mail]
Email*
Permittee Telephone [phone]
No. (Previous)
NEW Permittee [phone]
Telephone No.*
Permittee Mailing 2020 Energy Dr., 0, Apex, NC 27502
Address (Previous)
NEW Permittee Street Address
Mailing Address* 800 Gaston Road
Address Line 2
MC N05
City
State / Province / Region
Gastonia
NC
Postal / Zip Code
Country
28056
USA
Permittee Street 2020 Energy Dr., 0, Apex, NC 27502
Address (Previous)
NEW Permittee Street Street Address
Address* 800 Gaston Road
Address Line 2
MC N05
City
State / Province / Region
Gastonia
NC
Postal / Zip Code
Country
28056
USA
Change Requested Andrew Moore via Modification request submitted 6/21/2022.
by: * Include any additional correspondence records in the Repository COC folder.
Additional Information for this update to contact information:
Addional Explanation
(Optional)
Date * 06/27/2022