NCC204410_Contact Update Record (Leg Resp Change)_20220815

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Georgoulias, Bethany A 8/15/2022 1:49:24 PM (Contact Changes Submitted)

Certificate of NCC204410
Coverage (COC) No.* Enter the Certificate of Coverage Number (Use capital letters)
NC Reference No. NCG01-2020-4410
Original NOI No.* 32396
Project information associated with this permit (cannot change):
Permittee Listed Organizaiton cannot be changed (new COC required)
Public Service Company of North Carolina, Inc.
Project Name DENC M-201 Crossing at Broad River
Address 175 Ken Miller Road, Union, NC
County Rutherford
Latitude 35.2755
Longitude-81.9989
Date COC Issued* 10/01/2020
Prior Rescission Date This field will populate only if COC has already been rescinded.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 M. 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 P.O. Box 1398, 0, Gastonia, NC 28056
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
us
Permittee Street 800 Gaston Road, Building A, Gastonia, NC
Address (Previous) 28056
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
us
Change Requested Andrew Moore via Modification request submitted 8/11/2022.
by: * Include any additional correspondence records in the Repository COC folder.
Additional Information for this update to contact information:
Addional Explanation
(Optional)
Date * 08/15/2022