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Exhibit A Statement of Work Contract Term: 2015-2017 AMENDMENT #6 DOH Program Name or Title: Office of Drinking Water Group A Program - Effective January 1,2015 Local Health Jurisdiction Name: Kittitas County Public Health Department Contract Number: C17114 SOW Type: Revision Revision # (for this SOW) 1 Funding Source Federal Compliance Type of Payment ~ Federal Contractor (check if applicable) D Reimbursement ~ State D FFATA (Transparency Act) ~ Fixed Price D Other D Research & Deyelopment Period of Performance: January 1, 2015 through December 31,2017 Statement of Work Purpose: The purpose of this statement of work is to provide funding to the LHJ for conducting sanitary surveys and providing technical assistance to small community and non-community Group A water systems. Revision Purpose: The purpose of this revision is to extend the Funding Period from 12/31115 to 12/31116, increase Contract Consideration, and revise Special Billing Requirements and Special Instructions. Chart of Accounts Program Name or Title CFDA# BARS Master Funding Period Current Change Total Revenue Index (LHJ Use Only) Consideration Increase (+) Consideration Code Code Start Date End Date Drinking Water Group A -SS N/A 346.26.64 2421921C 01/01/15 12/31116 2,800 2,200 5,000 Drinking Water Group A -SS State N/A 346.26.65 2421252C 01/01115 12/31116 2,800 2,200 5,000 Drinking Water Group A -TA N/A 346.26.66 24219210 I 01/01115 12/31116 4,000 1,000 5,000 TOTALS 9,600 5,400 15,000 ------------------------------------------------------------------ Task Task! Activity/Description Number 1 Trained LHJ staff will conduct sanitary surveys of small community and non- community Group A water systems identified by the DOH Office of Drinking Water (ODW) Regional Office. See Special Instructions for task activity. Exhibit A, Statements of Work Revised as of January 15,2016 *May Support PHAB Standards/Measures Deliverables/Outcomes Provide Final* Sanitary Survey Reports to ODW Regional Office. Complete Sanitary Survey Reports shall include: 1. Cover letter identifying significant deficiencies, significant findings, observations, recommendations, and referrals for further ODW follow-up. 2. Completed Small Water System checklist. 3. Updated Water Facilities Inventory (WFI). Page 6 of \0 Due Date/Time Frame Payment Information and/or Amount Final Sanitary Survey Upon ODW acceptance Reports must be received of the Final Sanitary by the ODW Regional Survey Report, the LHJ Office within 30 calendar shall be paid $400 for days of conducting the each sanitary survey of a sanitary survey . non-community system with three or fewer connections. Upon ODW acceptance of the Final Sanitary Survey Report, the LHJ shall be paid $800 for each sanitary survey of a Contract Number C17114-6 I