NCC190898_Contact Update Record_20240725

Action History (UTC-05:00)Eastern Time(US&Canada)
Submit by bethany.georgoulias 7/25/2024 7:45:38 AM (Contact Changes Submitted)

Contact • - for • • • ONLY)
updatesThis form • . .
Certificate of NCC190898
Coverage(COC) No.* Enter the Certificate of Coverage Number(Use capital letters)
NC Reference No. NCG01-2019-0898
Original NOI No.* 13259
Project information associated with this permit(cannot change):
Permittee Listed Organizaiton cannot be changed(new COC required)
The City of Winston-Salem
Project Name Hanes MII LF Recycling Area
Address 325 W Hanes Mill Road,Winston-Salem, NC
County Forsyth
Latitude 36.1873
Longitude -80.2824
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Prior Rescission Date This field will populate only if COC has already been rescinded.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
4) Yes
Billing Email
NEW Billing Email [e-mail]
Billing Telephone No.
NEW Billing [phone]
Telephone No. (Optional)
Site Contact Information
REVISE ONLY WHERE NECESSARY. KEEP INFORMATION THESAME IF NO CHANGES!
Site Contact Keith Cain
(Previous)
Site Contact Title
(Previous)

Organization The City of Winston-Salem
(Previous)
First Name(New)* Gordon
Last Name(New)* Dively
NEW Site Contact* Reflects any revisions above
Gordon Dively
NEW Site Contact
Title
NEW Organization The City of Winston-Salem
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 336.399.5056
Telephone No.
(Previous)
NEW Site Contact [phone]
Telephone No.*
Site Contact Mailing 325 West Hanes Mill Road, 0,Winston-
Address(Previous) Salem, NC 27105-9626
NEW Site Contact Street Address
Mailing Address* 325 West Hanes Mill Road
Address Line 2
City State/Province/Region
Winston-Salem NC
Postal/Zip Code Country
27105-9626 us
Change Requested Gordon Dively(Solid Waste Operations Manager)via Modification request
by:* submitted 7/24/2024.
Include any additional correspondence records in the Repository COC folder.
Additional Information for this update to contact information:
Addional Explanation
(Optional)
Date* 07/25/2024