NCC204568_Annual Fee Payment Record_20211007

Action History (UTC-05:00) Eastern Time (US & Canada)
by Workflow 9/30/2021 1:36:52 PM (Workflow Start Event)
Submit by Selkane, Aziza 10/7/2021 2:36:22 PM (2021 Annual Fee Payment Verification for NCC204568-2021)
* Pinehursf Medical Group, LLC
• Selkane, Aziza assigned the task to Selkane, Aziza 10/7/2021 2:35 PM
The task was assigned to DEMLR NCG01 Annual Fee Team. The due date is: November 11, 2021 5:00
PM 9/30/2021 1:36 PM

C �
s
Li Annuai i�ee
NORTH cAR(DUNA
Environmental Quvllty
Certificate of
NCC204568
Coverage (COC)
This is passed fromthe workflow when the invoice is filed.
No.*
NC Reference COC
NCG01-2020-4568
No.*
Permit Status:
Active
Year COC Issued
2020
This field will be hidden.
2020 Fee Status
Check last year's fee status
Project Name*
Mid Carolina Gastroenterology Expansion
Project Address*
110 Dennis Dr, Sanford, NC
Permittee *
Pinehurst Medical Group, LLC
County
Lee
Invoice No.*
NCC204568-2021
This is passed fromthe workflow when the invoice is filed.
Annual Fee *
$ 100.00
Invoice Date*
10/1/2021
This is passed fromthe workflow when the invoice is filed.
Invoice Due Date*
11/1/2021
This is passed fromthe workflow when the invoice is filed.
An automated email reminder is sent to the permittee when the invoice is due. Wait until invoice is 15 days overdue
before proceeding to a Notice of Deficiency.
Important: If you change the choice below to Payment NOT RECEIVED, the fee status becomes PAST DUE, and the
permittee will receive a Notice of Deficiency.
Annual Fee Payment r Fee Payment Received or Not Applicable.
Received* r Fee Payment NOT RECEIVED.
Date Payment 10/7/2021
Received * Cr, if WANBD or NOT FECBV®, this is the date that status is recorded.
Method of Payment* r electronic
r check
f other
Check Number* 3684
Fee Status* PAID

Legally Responsible Brandon Enfinger
Person (Orig.)
Original Permittee E- [e-mail]
mail *
CONFIRM Permittee [e-mail]
E-mail * Opportunity to rrodify problem e-mail address or perrrittee contact info
Original Site Contact [e-mail]
E-mail *
CONFIRM Site [e-mail]
Contact E-mail * Opportunity to correct problem e-rrail address or site contact info
Original Billing E- (If available)
mail
CONFIRM Billing E- Opportunity to correct probleme-nail address or billing contact info
mail
Billing Telephone
No.
Permittee Email for [e-mail]
30-day Reminder This is the email for the 3t}day reminder if needed (passed fromworldlow).
Site Contact Email [e-mail]
for 30-day Reminder This is the email for the 3aday reminderif needed (passed fromworldlow)
Billing Contact Email This is theenailforthe3adayrerrinderifneeded (passed fromworldlow).
for 30-day Reminder
Additional Billing Contact E-mails
Additional E-mail for
CC:
Review Date * 10/7/2021