NCC233419_Contact Update Record_20241104

Action History (UTC-05:00)Eastern Time(US&Canada)
Submit by bethany.georgoulias 11/4/2024 1:19:52 PM(Contact Changes Submitted)

Contact • - for • • • ONLY)
updatesThis form • . .
Certificate of NCC233419
Coverage(COC) No.* Enter the Certificate of Coverage Number(Use capital letters)
NC Reference No. NCG01-2023-3419
Original NOI No.* 169697
Project information associated with this permit(cannot change):
Permittee Listed Organizaiton cannot be changed(new COC required)
City of Gastonia
Project Name Highland Branch Greenway
Address Rankin Lake Road,Gastonia, NC
County Gaston
Latitude 35.2927
Longitude -81.1830
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Prior Rescission Date This field will populate only if COC has already been rescinded.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 [e-mail]
NEW Billing Email [e-mail]
Billing Telephone No. 704-854-6635
NEW Billing [phone]
Telephone No. (Optional)
Legally Responsible Individual Contact Information
REVISE ONLY WHERE NECESSARY. KEEP INFORMATION THESAME IF NO CHANGES!
Legally Responsible Rusty Bost
Individual(Previous)
First Name(New)* Tucker
Last Name(New)* Johnson

NEW Legally Reflects any revisions above
Responsible Tucker Johnson
Individual*
Permittee Email [e-mail]
(Previous)
NEW Permittee [e-mail]
Email*
Permittee Telephone [phone]
No.(Previous)
NEW Permittee [phone]
Telephone No.*
Permittee Mailing PO Box 1748,0,Gastonia, North Carolina
Address(Previous) 28052-4121
NEW Permittee Street Address
Mailing Address* PO Box 1748
Address Line 2
City State/Province/Region
Gastonia North Carolina
Postal/Zip Code Country
28052-4121 United States
Permittee Street 150 South York Street,0,Gastonia, NC
Address(Previous) 28052-4121
NEW Permittee Street Street Address
Address* 150 South York Street
Address Line 2
City State/Province/Region
Gastonia NC
Postal/Zip Code Country
28052-4121 US
Change Requested Tucker.Johnson via Modification request submitted 11/1/2024.
by:* Include any additional correspondence records in the Repository COC folder.
Additional Information for this update to contact information:
Addional Explanation
(Optional)
Date* 11/04/2024