NCC215174_Contact Update Record_20230906

Action History (UTC-05:00)Eastern Time(US&Canada)
Submit by bethany.georgoulias 9/6/2023 8:09:49 AM(Contact Changes Submitted)

Contact • - for • • • ONLY)
updatesThis form • . .
Certificate of NCC215174
Coverage(COC) No.* Enter the Certificate of Coverage Number(Use capital letters)
NC Reference No. NCG01-2021-5174
Original NOI No.* 64723
Project information associated with this permit(cannot change):
Permittee Listed Organizaiton cannot be changed(new COC required)
Yadkin Valley Self Storage, LLC
Project Name Yadkin Valley Self Storage, LLC Addition
Address 639 CC Camp Road, Elkin, NC
County Surry
Latitude 36.2816
Longitude -80.8247
Date COC Issued* 09/14/2021
Prior Rescission Date This field will populate only if COC has already been rescinded.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
(.) Yes
Billing Email [e-mail]
NEW Billing Email [e-mail]
Billing Telephone No. 336-835-5105
NEW Billing [phone]
Telephone No. (optional)
Legally Responsible Individual Contact Information
REVISE ONLY WHERE NECESSARY. KEEP INFORMATION THESAME IF NO CHANGES!
Legally Responsible Michael Wilson
Individual(Previous)
First Name(New)* Benjamin E.
Last Name(New)* Mastin

NEW Legally Reflects any revisions above
Responsible Benjamin E. Mastin
Individual*
Permittee Email [e-mail]
(Previous)
NEW Permittee [e-mail]
Email*
Permittee Telephone [phone]
No.(Previous)
NEW Permittee [phone]
Telephone No.*
Permittee Mailing PO Box 589, 0, Elkin, NC 28621
Address(Previous)
NEW Permittee Street Address
Mailing Address* P.O. Box 589
Address Line 2
City State/Province/Region
Elkin NC
Postal/Zip Code Country
28621 USA
Permittee Street 639 CC Camp Road,0, Elkin, NC 28621
Address(Previous)
NEW Permittee Street Street Address
Address* 639 CC Camp Road
Address Line 2
City State/Province/Region
Elkin NC
Postal/Zip Code Country
28621 US
Site Contact Information
REVISE ONLY WHERE NECESSARY. KEEP INFORMATION THESAME IF NO CHANGES!
Site Contact Ben Mastin
(Previous)
Site Contact Title
(Previous)
Organization Yadkin Valley Self Storage, LLC
(Previous)
First Name(New)* Ben
Last Name(New)* Mastin
NEW Site Contact* Reflects any revisions above
Ben Mastin

NEW Site Contact President
Title
NEW Organization Yadkin Valley Self Storage, LLC
This field is not required on the NOI form and may not pre-populate.
Site Contact Email [e-mail]
(Previous)
NEW Site Contact [e-mail]
Email*
Site Contact 336-835-5105
Telephone No.
(Previous)
NEW Site Contact [phone]
Telephone No.*
Site Contact Mailing PO Box 589, 0, Elkin, NC 28621
Address(Previous)
NEW Site Contact Street Address
Mailing Address* P.O. Box 589
Address Line 2
City State/Province/Region
Elkin NC
Postal/Zip Code Country
28621 US
Change Requested Benjamin Mastin via Modification request submitted 9/1/2023.
by:* Include any additional correspondence records in the Repository COC folder.
Additional Information for this update to contact information:
Addional Explanation Alternate number for B. Mastin is(336)366-1100(listed for billing contact info).
(Optional) Updated site contact phone for consistency.
Date* 09/06/2023