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Exhibit A Statement of Work Contract Term: 2015-2017 AMENDMENT #9 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: Cl71l4 SOW Type: Revision Revision # (for this SOW) 3 Funding Source Federal Compliance Type of Payment [gI Federal Contractor (check if applicable) o Reimbursement [gI State o FF A TA (Transparency Act) [gI Fixed Price o Other o Research & Development Period of Performance: January 1, 20 IS 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 increase contract Consideration, add language to the Payment Information on Task 4, revise Special Billing Requirements and Special Instructions, and change DOH Contact Names. 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 01101115 12/31/16 5,000 1,600 6,600 Drinking Water Group A -SS State N/A 346.26.65 2421252C 01 /01115 12/31116 5,000 1,600 6,600 Drinking Water Group A -TA N /A 346.26.66 24219210 01 /01115 12 /31116 5,000 -1 ,600 3,400 TOTALS ------- !5,OOO 1,600 16,600 Task Task! Activity/Description *May Support PHAB Delivera bles/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 ODW acceptance surveys of small community and non-Reports to ODW Regional Office. Reports must be received of the Final Sanitary community Group A water systems Complete Sanitary Survey Reports by the ODW Regional Survey Report, the LHJ I identified by the DOH Office of Drinking shall include: Office within 30 calendar shall be paid $400 for I Water (ODW) Regional Office. l. Cover letter identifying days of conducting the each sanitary survey of a See Special Instructions for task activity . Exhibit A, Statements of Work Revised as of September 15,2016 : significant deficiencies, significant findings, observations, recommendations, and referrals for further ODW follow-up. 2. Completed Small Water System checklist. 3. Updated Water Facilities Inventory (WFl). Page 3 of7 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 C17114-9