NCC204741_Contact Update Record (Leg Resp Change)_20220826

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by Georgoulias, Bethany A 8/26/2022 12:59:56 PM (Contact Changes Submitted)

Certificate of
NCC204741
Coverage (COC) No.*
Enter the Certificate of Coverage Number (Use capital letters)
NC Reference No.
NCG01-2020-4741
Original NOI No.*
33324
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 Dominion Energy -Bright Farm 4" Extension
Address Pleasant Grove Rd., Etowah, NC
County Henderson
Latitude 35.2970
Longitude-82.6016
Date COC Issued * 10/28/2020
Prior Rescission Date This field will populate only if COC has already been rescinded.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 800 Gaston Road, Building A, 0, Gastonia,
Address (Previous) NC 28056
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, 0, Gastonia,
Address (Previous) NC 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 (Director - Engineering & Construction) via Modification request
by: * submitted 8/24/2022.
Include any additional correspondence records in the Repository COC folder.
Additional Information for this update to contact information:
Addional Explanation
(Optional)
Date * 08/26/2022