NCC240033_Contact Update Record (Email Correction)_20250106

Action History (UTC-05:00)Eastern Time(US&Canada)
Submit by bethany.georgoulias 1/6/2025 8:37:49 AM(Contact Changes Submitted)

Contact • - for • • • ONLY)
updatesThis form • . .
Certificate of NCC240033
Coverage(COC) No.* Enter the Certificate of Coverage Number(Use capital letters)
NC Reference No. NCG01-2024-0033
Original NOI No.* 176587
Project information associated with this permit(cannot change):
Permittee Listed Organizaiton cannot be changed(new COC required)
Cypress Glen Retirement Community
Project Name Cypress Glen Expansion
Address 207 Hickory Street,Greenville, NC
County Pitt
Latitude 35.6099
Longitude -77.3473
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Prior Rescission Date This field will populate only if COC has already been rescinded.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
0 Yes
Billing Email [e-mail]
NEW Billing Email [e-mail]
Billing Telephone No. 252-830-0036
NEW Billing [phone]
Telephone No. (Optional)
Legally Responsible Individual Contact Information
REVISE ONLY WHERE NECESSARY. KEEP INFORMATION THESAME IF NO CHANGES!
Legally Responsible Laurie Stallings
Individual(Previous)
First Name(New)* Laurie
Last Name(New)* Stallings

NEW Legally Reflects any revisions above
Responsible Laurie Stallings
Individual*
Permittee Email [e-mail]
(Previous)
NEW Permittee [e-mail]
Email*
Permittee Telephone [phone]
No.(Previous)
NEW Permittee [phone]
Telephone No.*
Permittee Mailing 100 Hickory Street, 0, Greenville, NC 27858-
Address(Previous) 1636
NEW Permittee Street Address
Mailing Address* 100 Hickory Street
Address Line 2
City State/Province/Region
Greenville NC
Postal/Zip Code Country
27858-1636 United States
Permittee Street 207 Hickory Street, 0, Greenville, NC 27858-
Address(Previous) 1636
NEW Permittee Street Street Address
Address* 207 Hickory Street
Address Line 2
City State/Province/Region
Greenville NC
Postal/Zip Code Country
27858-1636 US
Change Requested Email typo correction, requested by Eric Deal(Director of Plant Operations)via
by: email on 1/2/2025.
Include any additional correspondence records in the Repository COC folder.
Additional Information for this update to contact information:
Addional Explanation
(Optional)
Date* 01/06/2025