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Exhibit A <br />Statement of Work <br />Contract Term: 2015-2017 <br />AMENDMENT #10 <br />DOH Program Name or Title: Office of Drinking Water Group B Program- <br />Effective January I, 2017 <br />Local Health Jurisdiction Name: Kittitas County Public Health Department <br />Contract Number: CI7114 <br />SOW Type: Original Revision # (for this SOW) Funding Source Federal Compliance Type of Payment o Federal <Select One> (check if applicable) o Reimbursement <br />I:8l State o FF A T A (Transparency Act) I:8l Fixed Price o Other o Research_ & Development <br />Period of Performance: January I, 2017 through December 31, 2017 <br />Statement of Work Purpose: The purpose of this statement of work is to provide financial support to LHJs implementing local Group B water system programs. <br />Revision Purpose: N/A <br />Chart of Accounts Program Name or Title CFDA# BARS Master Funding Period Current Change Irotal <br />Revenue Index (LUJ Use Only) Consideration Increase (+) Consideration <br />Code Code Start Date End Date <br />Drinking Water Group_ B N/A 334.04.90 24240103 01/01117 I 06/30117 0 5,000 5,000 <br />Drinking Water Group B N/A 334.04.90 24240103 07 /01117 I 12/31117 0 5,000 5_,000 <br />TOTALS 0 10,000 lO~OOO <br />Task Task! Activity/Description *May Support PHAB Deliverables/Outcomes Joint Plan of Payment Information <br />Number StandardslMeasures Responsibility Number and/or Amount <br />I Implement a full Group B water system program An executed joint plan of Reference DOH JPR Semi-annual lump sum <br />responsibility (JPR) with DOH #NI9411 payments (See Special <br />identifying responsibilities of a Billing Requirements) <br />full Grou~ B program. <br />*For Information Only: <br />Funding is not tied to the revised Standards/Measures listed here. This information may be helpful in discussions of how program activities might contribute to meeting a <br />Standard/Measure. More detail on these and/or other Public Health Accreditation Board (PHAB) Standards/Measures that may apply can be found at: <br />http://w ww .p haboard.orglwp-comentiupioads /P H AB_Sta ndard s-and-M easures -VeTS ion -I .O.p df <br />Program Specific Reg uirements/N arrative <br />Special Billing Requirements <br />The LHJ shall submit semi-annual invoices as follows: $5,000 in the first half of the calendar year and $5,000 in the second half of the calendar year. Payment cannot exceed a <br />maximum accumulative fee of $1 0,000 per year. <br />Exhibit A, Statements of Work <br />Revised as of November 15,2016 <br />Page 13 of21 Contract Number C 17114-10