NCC192992_Contact Update Record (LEG RESP CHANGE)_20240117

Action History (UTC-05:00)Eastern Time(US&Canada)
Submit by bethany.georgoulias 1/17/2024 1:08:52 PM (Contact Changes Submitted)

Contact • - for • • • ONLY)
updatesThis form • . .
Certificate of NCC192992
Coverage(COC) No.* Enter the Certificate of Coverage Number(Use capital letters)
NC Reference No. NCG01-2019-2992
Original NOI No.* 19001
Project information associated with this permit(cannot change):
Permittee Listed Organizaiton cannot be changed(new COC required)
Carolina Raptor Center
Project Name Carolina Raptor Center
Address Sample Road, Huntersville, NC
County Mecklenburg
Latitude 35.3588
Longitude -80.9082
Date COC Issued* 12/13/2019
Prior Rescission Date This field will populate only if COC has already been rescinded.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]
Telephone No. (Optional)
Legally Responsible Individual Contact Information
REVISE ONLY WHERE NECESSARY. KEEP INFORMATION THESAME IF NO CHANGES!
Legally Responsible Jim Warren
Individual(Previous)
First Name(New)* Erin
Last Name(New)* Katzner

NEW Legally Reflects any revisions above
Responsible Erin Katzner
Individual*
Permittee Email [e-mail]
(Previous)
NEW Permittee [e-mail]
Email*
Permittee Telephone [phone]
No.(Previous)
NEW Permittee [phone]
Telephone No.*
Permittee Mailing 6000 Sample Road,0, Huntersville, NC
Address(Previous) 28078
NEW Permittee Street Address
Mailing Address* 6000 Sample Road
Address Line 2
City State/Province/Region
Huntersville NC
Postal/Zip Code Country
28078 us
Permittee Street 6000 Sample Road,0, Huntersville, NC
Address(Previous) 28078
NEW Permittee Street Street Address
Address* 6000 Sample Road
Address Line 2
City State/Province/Region
Huntersville NC
Postal/Zip Code Country
28078 us
Change Requested Erin Katzner(President&CEO)via email on 1/17/2024.
by:* Include any additional correspondence records in the Repository COC folder.
Additional Information for this update to contact information:
Addional Explanation
(Optional)
Date* 01/17/2024