NCC230136_Contact Update Record_20240103

Action History (UTC-05:00)Eastern Time(US&Canada)
Submit by Tev.Holloman 1/3/2024 8:08:29 AM(Contact Changes Submitted)

Contact • - for • • • ONLY)
updatesThis form • . .
Certificate of NCC230136
Coverage(COC) No.* Enter the Certificate of Coverage Number(Use capital letters)
NC Reference No. NCG01-2023-0136
Original NOI No.* 122754
Project information associated with this permit(cannot change):
Permittee Listed Organizaiton cannot be changed(new COC required)
ARE-NC Region No.25, LLC
Project Name NextGen
Address 3029 East Cornwallis Road, Durham, NC
County Durham
Latitude 35.9147
Longitude -78.8678
Date COC Issued* 01/19/2023
Prior Rescission Date This field will populate only if COC has already been rescinded.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? 0• No
0 Yes
Billing Email [e-mail]
Billing Telephone No. 919-313-6645
Site Contact Information
REVISE ONLY WHERE NECESSARY. KEEP INFORMATION THESAME IF NO CHANGES!
Site Contact Brika Eklund
(Previous)
Site Contact Title
(Previous)
Organization
(Previous)
First Name(New)* Leon

Last Name(New)* Kislowski
NEW Site Contact* Reflects any revisions above
Leon Kislowski
NEW Site Contact
Title
NEW Organization 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 919-313-6645
Telephone No.
(Previous)
NEW Site Contact 919-313-6645
Telephone No.*
Site Contact Mailing 12 Davis Drive, PO Box 13329, Durham, NC
Address(Previous) 27709-0003
NEW Site Contact Street Address
Mailing Address* 12 Davis Drive
Address Line 2
PO Box 13329
City State/Province/Region
Durham NC
Postal/Zip Code Country
27709-0003 us
Change Requested David Lee, Project Coordinator,via email on 1/2/2024
by:* Include any additional correspondence records in the Repository COC folder.
Additional Information for this update to contact information:
Addional Explanation
(Optional)
Date* 01/03/2024