NCC205997_Contact Update Record (Legally Resp Change)_20230417

Action History (UTC-05:00)Eastern Time(US&Canada)
Submit by bethany.georgoulias 4/17/2023 12:49:44 PM(Contact Changes Submitted)

Contact • - for • • • ONLY)
updatesThis form • . .
Certificate of NCC205997
Coverage(COC) No.* Enter the Certificate of Coverage Number(Use capital letters)
NC Reference No. NCG01-2020-5997
Original NOI No.* 39922
Project information associated with this permit(cannot change):
Permittee Listed Organizaiton cannot be changed(new COC required)
PV Transport, Inc.
Project Name PV Transport, Inc.(Truck Wash Facility)
Address 1287 Greenville Avenue,Williamston, NC
County Martin
Latitude 35.8430
Longitude -77.0892
Date COC Issued* 01/05/2021
Prior Rescission Date This field will populate only if COC has already been rescinded.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
4) 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 Robert Drygas
Individual(Previous)
First Name(New)* Mark
Last Name(New)* Licwinko

NEW Legally Reflects any revisions above
Responsible Mark Licwinko
Individual*
Permittee Email [e-mail]
(Previous)
NEW Permittee [e-mail]
Email*
Permittee Telephone [phone] ext 8834
No.(Previous)
NEW Permittee [phone]
Telephone No.*
Permittee Mailing 2704 Clemens Road,0, Hatfield, Pa 19440
Address(Previous)
NEW Permittee Street Address
Mailing Address* 2500 Clemens Road
Address Line 2
City State/Province/Region
Hatfield Pa
Postal/Zip Code Country
19440 USA
Permittee Street PO Box 902, 0, Hatfield, Pa 19440
Address(Previous)
NEW Permittee Street Street Address
Address* 2500 Clemens Road
Address Line 2
City State/Province/Region
Hatfield Pa
Postal/Zip Code Country
19440 USA
Change Requested William Fink via e-mail on 4/17/2023.
by:* Include any additional correspondence records in the Repository COC folder.
Additional Information for this update to contact information:
Addional Explanation
(Optional)
Date* 04/17/2023