NCC215916_Contact Update Record_20230925

Action History (UTC-05:00)Eastern Time(US&Canada)
Submit by bethany.georgoulias 9/25/2023 9:11:15 AM(Contact Changes Submitted)

Contact • - for • • • ONLY)
updatesThis form • . .
Certificate of NCC215916
Coverage(COC) No.* Enter the Certificate of Coverage Number(Use capital letters)
NC Reference No. NCG01-2021-5916
Original NOI No.* 69506
Project information associated with this permit(cannot change):
Permittee Listed Organizaiton cannot be changed(new COC required)
Fujif!Im Diosynth Biotechnologies USA, Inc.
Project Name FDB Project Galaxy-Early Grading
Address 11751 Holly Springs New Hill Road, Holly Springs, NC
County Wake
Latitude 35.6553
Longitude -78.8735
Date COC Issued* 10/28/2021
Prior Rescission Date This field will populate only if COC has already been rescinded.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 [e-mail]
NEW Billing Email [e-mail]
Billing Telephone No. 9195832686
NEW Billing [phone]
Telephone No. (Optional)
Legally Responsible Individual Contact Information
REVISE ONLY WHERE NECESSARY. KEEP INFORMATION THESAME IF NO CHANGES!
Legally Responsible Thomas Schmalzbauer
Individual(Previous)
First Name(New)* Jordan
Last Name(New)* Ulrich

NEW Legally Reflects any revisions above
Responsible Jordan Ulrich
Individual*
Permittee Email [e-mail]
(Previous)
NEW Permittee [e-mail]
Email*
Permittee Telephone [phone]
No.(Previous)
NEW Permittee [phone]
Telephone No.*
Permittee Mailing 101 J Morris Commons Lane,0, Morrisville,
Address(Previous) NC 27560-8884
NEW Permittee Street Address
Mailing Address* 101 J Morris Commons Lane
Address Line 2
City State/Province/Region
Morrisville NC
Postal/Zip Code Country
27560-8884 US
Permittee Street 101 J Morris Commons Lane,0, Morrisville,
Address(Previous) NC 27560-8884
NEW Permittee Street Street Address
Address* 101 J Morris Commons Lane
Address Line 2
City State/Province/Region
Morrisville NC
Postal/Zip Code Country
27560-8884 US
Site Contact Information
REVISE ONLY WHERE NECESSARY. KEEP INFORMATION THESAME IF NO CHANGES!
Site Contact Thomas Schmalzbauer
(Previous)
Site Contact Title Head of Secondary Buildings
(Previous)
Organization Fujifilm Diosynth Biotechnologies USA
(Previous)
First Name(New)* Jordan
Last Name(New)* Ulrich
NEW Site Contact* Reflects any revisions above
Jordan Ulrich

NEW Site Contact Vice President of Project Delivery
Title
NEW Organization Fujifilm Diosynth Biotechnologies USA, Inc.
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 9195832686
Telephone No.
(Previous)
NEW Site Contact [phone]
Telephone No.*
Site Contact Mailing 101 J Morris Commons Lane,0, Morrisville,
Address(Previous) NC 27560-8884
NEW Site Contact Street Address
Mailing Address* 101 J Morris Commons Lane
Address Line 2
City State/Province/Region
Morrisville NC
Postal/Zip Code Country
27560-8884 US
Change Requested J. Ulrich via Modification request submitted 9/21/2023.
by:* Include any additional correspondence records in the Repository COC folder.
Additional Information for this update to contact information:
Addional Explanation
(Optional)
Date* 09/25/2023