NCC216686_Contact Update Record_20231018

Action History (UTC-05:00)Eastern Time(US&Canada)
Submit by bethany.georgoulias 10/18/2023 8:48:08 AM(Contact Changes Submitted)

Contact • - for • • • ONLY)
updatesThis form • . .
Certificate of NCC216686
Coverage(COC) No.* Enter the Certificate of Coverage Number(Use capital letters)
NC Reference No. NCG01-2021-6686
Original NOI No.* 74601
Project information associated with this permit(cannot change):
Permittee Listed Organizaiton cannot be changed(new COC required)
Sampson County
Project Name South Eldridge Road Water Main Extension
Address South Eldridge Road(SR-1644), Newton Grove, NC
County Sampson
Latitude 35.2112
Longitude -78.4129
Date COC Issued* 01/05/2022
Prior Rescission Date This field will populate only if COC has already been rescinded.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
0 Yes
Billing Email [e-mail]
NEW Billing Email [e-mail]
Billing Telephone No. 910.592.0188
NEW Billing [phone]
Telephone No. (optional)
Legally Responsible Individual Contact Information
REVISE ONLY WHERE NECESSARY. KEEP INFORMATION THESAME IF NO CHANGES!
Legally Responsible Linwood Reynolds
Individual(Previous)
First Name(New)* Linwood
Last Name(New)* Reynolds

NEW Legally Reflects any revisions above
Responsible Linwood Reynolds
Individual*
Permittee Email [e-mail]
(Previous)
NEW Permittee [e-mail]
Email*
Permittee Telephone [phone]
No.(Previous)
NEW Permittee [phone]
Telephone No.*
Permittee Mailing 827 Southeast Boulevard,0, Clinton, NC
Address(Previous) 28328-4321
NEW Permittee Street Address
Mailing Address* 827 Southeast Boulevard
Address Line 2
City State/Province/Region
Clinton NC
Postal/Zip Code Country
28328-4321 us
Permittee Street 827 Southeast Boulevard,0, Clinton, NC
Address(Previous) 28328-4321
NEW Permittee Street Street Address
Address* 827 Southeast Boulevard
Address Line 2
City State/Province/Region
Clinton NC
Postal/Zip Code Country
28328-4321 us
Change Requested Mark Turlington(Public Works Director)via Modification request submitted
by:* 10/17/2023.
Include any additional correspondence records in the Repository COC folder.
Additional Information for this update to contact information:
Addional Explanation
(Optional)
Date* 10/18/2023