NCC200776_Contact Update Record (Site Contact)_20240214

Action History (UTC-05:00)Eastern Time(US&Canada)
Submit by bethany.georgoulias 2/14/2024 10:58:52 AM(Contact Changes Submitted)

Contact • - for • • • ONLY)
updatesThis form • . .
Certificate of NCC200776
Coverage(COC) No.* Enter the Certificate of Coverage Number(Use capital letters)
NC Reference No. NCG01-2020-0776
Original NOI No.* 22441
Project information associated with this permit(cannot change):
Permittee Listed Organizaiton cannot be changed(new COC required)
Vineyards Management Group
Project Name Creekside Mobile Home Park
Address 400 Stoney Creek Dr, Reidsville, NC
County Rockingham
Latitude 36.3390
Longitude -79.6330
Date COC Issued* 03/06/2020
Prior Rescission Date This field will populate only if COC has already been rescinded.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
C) Yes
Billing Email [e-mail]
Billing Telephone No. [phone]
Site Contact Information
REVISE ONLY WHERE NECESSARY. KEEP INFORMATION THESAME IF NO CHANGES!
Site Contact Stephen Walker
(Previous)
Site Contact Title Owner
(Previous)
Organization Stephen Walker Grading and Hauling
(Previous)
First Name(New)* Duaine

Last Name(New)* Hatch
NEW Site Contact* Reflects any revisions above
Duaine Hatch
NEW Site Contact VP of Capital Improvements
Title
NEW Organization Roots Management Group, 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 336-932-1242
Telephone No.
(Previous)
NEW Site Contact [phone]
Telephone No.*
Site Contact Mailing 1580 Moir Mill Road,0, Reidsville, NC 27320-
Address(Previous) 8003
NEW Site Contact Street Address
Mailing Address* 400 Stoney Creek Drive
Address Line 2
City State/Province/Region
Reidsville NC
Postal/Zip Code Country
27320-8003 us
Change Requested Tina Graska via email on 2/13/2024.
by:* Include any additional correspondence records in the Repository COC folder.
Additional Information for this update to contact information:
Addional Explanation
(Optional)
Date* 02/14/2024