NCC240233_Contact Update Record_20240408

Action History (UTC-05:00)Eastern Time(US&Canada)
Submit by bethany.georgoulias 4/8/2024 11:58:47 AM(Contact Changes Submitted)

Contact • - for • • • ONLY)
updatesThis form • . .
Certificate of NCC240233
Coverage(COC) No.* Enter the Certificate of Coverage Number(Use capital letters)
NC Reference No. NCG01-2024-0233
Original NOI No.* 179138
Project information associated with this permit(cannot change):
Permittee Listed Organizaiton cannot be changed(new COC required)
NC Dept.of Public Safety
Project Name Richmond Youth Development Center
Address 269 Cartledge Creek Road, Rockingham, NC
County Richmond
Latitude 34.9635
Longitude -79.7953
Date COC Issued* 04/01/2024
Prior Rescission Date This field will populate only if COC has already been rescinded.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 [e-mail]
NEW Billing Email [e-mail]
Billing Telephone No. 919-801-8328
NEW Billing [phone]
Telephone No. (optional)
Legally Responsible Individual Contact Information
REVISE ONLY WHERE NECESSARY. KEEP INFORMATION THESAME IF NO CHANGES!
Legally Responsible Daron Blount
Individual(Previous)
First Name(New)* Jeffrey
Last Name(New)* O'Briant

NEW Legally Reflects any revisions above
Responsible Jeffrey O'Briant
Individual*
Permittee Email [e-mail]
(Previous)
NEW Permittee [e-mail]
Email*
Permittee Telephone [phone]
No.(Previous)
NEW Permittee [phone]
Telephone No.*
Permittee Mailing 512 North Salisbury Street,4201 MSC,
Address(Previous) Raleigh, NC 27604
NEW Permittee Street Address
Mailing Address* 512 North Salisbury Street
Address Line 2
4201 MSC
City State/Province/Region
Raleigh NC
Postal/Zip Code Country
27699-4201 us
Permittee Street 512 North Salisbury Street,4201 MSC,
Address(Previous) Raleigh, NC 27604
NEW Permittee Street Street Address
Address* 512 North Salisbury Street
Address Line 2
Floor 2
City State/Province/Region
Raleigh NC
Postal/Zip Code Country
27604 us
Site Contact Information
REVISE ONLY WHERE NECESSARY. KEEP INFORMATION THESAME IF NO CHANGES!
Site Contact Daron Blount
(Previous)
Site Contact Title Project Manager
(Previous)
Organization NC Dept.of Public Safety
(Previous)
First Name(New)* Daron
Last Name(New)* Blount

NEW Site Contact* Reflects any revisions above
Daron Blount
NEW Site Contact Project Manager
Title
NEW Organization NC Dept.of Public Safety
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 919-801-8328
Telephone No.
(Previous)
NEW Site Contact [phone]
Telephone No.*
Site Contact Mailing 512 North Salisbury Street,4201 MSC,
Address(Previous) Raleigh, NC 27604
NEW Site Contact Street Address
Mailing Address* 512 North Salisbury Street
Address Line 2
4201 MSC
City State/Province/Region
Raleigh NC
Postal/Zip Code Country
27699-4201 us
Change Requested Modification request submitted by Jeffrey O'Briant(DPS Director Engineering)on
by:* 3/22/2024
Include any additional correspondence records in the Repository COC folder.
Additional Information for this update to contact information:
Addional Explanation
(Optional)
Date* 04/08/2024