NCC202386_Annual Fee Payment Record_20220628

Action History (UTC-05:00) Eastern Time (US & Canada)
by Workflow 5/28/2022 11:06:25 AM (Workflow Start Event)
Submit by Georgoulias, Bethany A 6/28/2022 9:47:51 AM (2022 Annual Fee Payment Verification for NCC202386-
2022)
0 Silas L. Haynes
• Georgoulias, Bethany A assigned the task to Georgoulias, Bethany A 6/28/2022 9:47 AM
• The task was assigned to DEMLR NCG01 Annual Fee Team. The due date is: July 11, 2022 5:00 PM
5/28/2022 11:06 AM

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NORTH CAROLINA
Envlrmmm(af Quafhy
Certificate of
NCC202386
Coverage (COC) No. *
This is passed from the workflow when the invoice is filed.
NC Reference COC
NCG01-2020-2386
No. *
Permit Status:
Active
Year COC Issued
2020
This field will be hidden.
Check previous years for outstanding fees (years that do not apply will be blank):
2020 Fee Status
2021 Fee Status
PAID
Project Name*
2020 BUILDING ADDITION AT GIBSON CANCER CENTER
Project Address*
PINE RUN DRIVE, LUMBERTON, NC
Permittee*
SOUTHEASTERN REGIONAL MEDICAL CENTER
County
Robeson
Invoice No.*
NCC202386-2022
This is passed from the workflow when the invoice is filed.
Annual Fee*
$ 100.00
Invoice Date*
6/1/2022
This is passed from the workflow when the invoice is filed.
Invoice Due Date*
7/1/2022
This is passed from the 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 • Fee Payment Received or Not Applicable.
Received* Fee Payment NOT RECEIVED.
Date Payment 6/28/2022
Received * Or, if WAIVED or NOT RECEIVED, this is the date that status is recorded.
Method of Payment* electronic
check
other

ePayment 640329866
Transaction Number*
Fee Status* PAID
Legally Responsible Jason Cox
Person (Orig.)
Original Permittee E- [e-mail]
mail *
CONFIRM Permittee [e-mail]
E-mail * Opportunity to modify problem e-mail address or permittee contact info
Original Site Contact [e-mail]
E-mail*
CONFIRM Site [e-mail]
Contact E-mail* Opportunity to correct problem e-mail address or site contact info
Original Billing E-mail (If available)
CONFIRM Billing E- Opportunity to correct problem e-mail address or billing contact info
mail
Billing Telephone No.
Permittee Email for [e-mail]
30-day Reminder This is the email for the 30-day reminder if needed (passed from workflow).
Site Contact Email for [e-mail]
30-day Reminder This is the email for the 30-day reminder if needed (passed from workflow)
Billing Contact Email This is the email for the 30-day reminder if needed (passed from workflow).
for 30-day Reminder
Project Name for 30- 2020 BUILDING ADDITION AT GIBSON CANCER CENTER
day Reminder The project name is passed from workflow for the 30-day reminder
Permittee Name for
SOUTHEASTERN REGIONAL MEDICAL CENTER
30-day Reminder
The permittee is passed from workflow for the 30-day reminder
County for 30-day
Robeson
Reminder
The county is passed from workflow for the 30-day reminder
Additional Billing Contact E-mails
Additional E-mail for
CC:
Review Date* 6/28/2022