PSA between Kittitas County Public Health and Comm Health of Central WA

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Exhibit A Statement of Work Contract Term: 2015-2017 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: CI7114 SOW Type: Original Revision # (for this SOW) Funding Source Federal Compliance Type of Payment ~ Federal Contractor (check ifapplicable) o Reimbursement ~ State o FF A T A (Transparency Act) ~ Fixed Price o Other o Research & Development 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: NI A Chart of Accounts Program Name or Title CFDA# BARS Master Funding Period Current Change rrotal 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 01/01115 12/31115 0 2,800 2,800 Drinking Water Group A -SS State N/A 346.26.65 2421252C 01/01/15 12/31/15 o I 2,800 2,800 Drinking Water Group A - T A N/A 346.26.66 2421921D 01/01115 12/31/15 0 4,000 4,000 TOTALS 0 9,600 9.600 Task Task! ActMty /Description *May Support PHAB Deliverables/Outcomes Due Date/Time Frame Payment Information Number StandardsIMeasures and/or Amount 1 Trained LHJ staff will conduct sanitary Provide Final* Sanitary Survey Final Sanitary Survey Upon ODWacceptance surveys of small community and non-Reports to OOW Regional Office. Reports must be received of the Final Sanitary community Group A water systems Complete Sanitary Survey Reports by the OOW Regional Survey Report, the LHJ identified by the DOH Office of Drinking shall include: Office within 30 calendar shall be paid $400 for Water (OOW) Regional Office. \. Cover letter identifying days of conducting the each sanitary survey of a significant deficiencies, sanitary survey. non-community system See Special Instructions for task activity . significant findings, with three or fewer observations, recommendations, connections. and referrals for further OOW follow-up. Upon ODW acceptance 2. Completed Small Water System of the Final Sanitary checklist. Survey Report, the LHJ 3. Updated Water Facilities shall be paid $800 for Inventory (WFI). each sanitary survey of a 4. Photos of water system with text non-community system identifying features with four or more Exhibit A, Statements of Work Page 9 of 19 Contract Number Cl7114