NCC204387_NOI 32374 Payment Verification_20201002

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 10/1/2020 10:09:03 AM (NCG01 NOI Submission)
Approve by Clark, Paul 10/1/2020 2:11:50 PM (Review- Construction NOI 32374)
• The task was assigned to Clark, Paul by round robin distribution 10/1/2020 10:09 AM
The task was assigned to DEMLR NCG01 NOI Review Team. The due date is: October 5, 2020 5:00
PM 10/1/2020 10:09 AM
Submit by Selkane, Aziza 10/2/2020 10:21:35 AM (Payment Verification for NCC204387)
* Marshia S. Coe
• Selkane, Aziza assigned the task to Selkane, Aziza 10/2/2020 10:20 AM
The task was assigned to DEMLR NCG01 Payment Team. The due date is: November 12, 2020 5:00
PM 10/1/2020 2:12 PM

SfA7$ q,
•
V.
• yrnent Verification
NORTH CAROLINA
Envlro me tufQuuftty
Project Name
HSM Dialysis Centers, LLC
NC Reference No.*
NCG01-2020-4387
Certificate of
NCC204387
Coverage (COC)
No. *
Invoice Date
10/1/2020
Initial Invoice No.
NCC204387-2020
Initial Fee
$ 100.00
Invoice Due Date
10/31/2020
Important: If you change
the choice below to Payment NOT RECEIVED, the application will be rejected, and a COC will
not be issued. This is the ONLY way to reject an eNO1 at this step.
Payment Received* r Payment Received.
r Payment NOT RECEIVED.
Payment Status
PAID
Date Payme nt
10/2/2020
Received *
(Or, if not received, date rejected for no payrrent)
Method of Payment*
r electronic
r check
r NO PAYMENT RECEIVED
f Other
ePayment
538122409
Transaction
Number*
NOI Tracking No.
32374
Tracking ID referenced upon subnittal
This is an Express
r No
Review Project
r Yes
Project Tracking ID
NCC-DAVID-2020-HSM Dialysis Centers, LLC