NCC204801_Contact Update Record_20231212

Action History (UTC-05:00)Eastern Time(US&Canada)
Submit by bethany.georgoulias 12/12/2023 8:24:51 AM(Contact Changes Submitted)

Contact • - for • • • ONLY)
updatesThis form • . .
Certificate of NCC204801
Coverage(COC) No.* Enter the Certificate of Coverage Number(Use capital letters)
NC Reference No. NCG01-2020-4801
Original NOI No.* 33827
Project information associated with this permit(cannot change):
Permittee Listed Organizaiton cannot be changed(new COC required)
Camden County
Project Name Camden Commerce Park
Address US Hwy 17,South Mills, NC
County Camden
Latitude 36.5205
Longitude -76.3614
Date COC Issued* 10/26/2020
Prior Rescission Date This field will populate only if COC has already been rescinded.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? Q No
Yes
Billing Email
NEW Billing Email [e-mail]
Billing Telephone No.
NEW Billing [phone] ext 310
Telephone No. (optional)
Legally Responsible Individual Contact Information
REVISE ONLY WHERE NECESSARY. KEEP INFORMATION THESAME IF NO CHANGES!
Legally Responsible Ken Bowman
Individual(Previous)
First Name(New)* Erin
Last Name(New)* Burke

NEW Legally Reflects any revisions above
Responsible Erin Burke
Individual*
Permittee Email [e-mail]
(Previous)
NEW Permittee [e-mail]
Email*
Permittee Telephone [phone]
No.(Previous)
NEW Permittee [phone] ext 310
Telephone No.*
Permittee Mailing PO Box 190, 0, Camden, North Carolina
Address(Previous) 27921
NEW Permittee Street Address
Mailing Address* PO Box 190
Address Line 2
City State/Province/Region
Camden North Carolina
Postal/Zip Code Country
27921 United States
Permittee Street 117 NC Hwy 343 North,0,Camden, North
Address(Previous) Carolina 27921
NEW Permittee Street Street Address
Address* 330 East Highway 158
Address Line 2
City State/Province/Region
Camden North Carolina
Postal/Zip Code Country
27921 Untied States
Change Requested Stephanie B Jackson (Finance Officer)via Modification request submitted
by:* 12/8/2023.
Include any additional correspondence records in the Repository COC folder.
Additional Information for this update to contact information:
Addional Explanation
(Optional)
Date* 12/12/2023