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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 A Program- <br />Effective January 1.2015 <br />Local Health Jurisdiction Name: Kittitas County Public Health Department <br />Contract Number: C17114 <br />SOW Type: Revision Revision # (for this SOW) 4 Funding Source Federal Compliance Type of Payment <br />~ Federal Contractor (check if applicable) D Reimbursement <br />~ State D FF A T A (Transparency Act) ~ Fixed Price <br />D Other D Research & Development <br />Period of Performance: January 1, 2015 through December 31, 2017 <br />Statement of Work Purpose: The purpose ofthis statement of work is to provide funding to the LHJ for conducting sanitary surveys and providing technical assistance to small <br />community and non-community Group A water systems. <br />Revision Purpose: The purpose of this revision is to increase funding consideration and extend funding period end dates from 12/31116 to 12/31117, revise Payment Information <br />on Task 4, and revise Special Billing Requirements and Special Instructions. <br />Chart of Accounts Program Name or Title <br />Drinking Water Group A -SS <br />Drinking Water Group A -SS State <br />Drinking Water Group A -TA <br />TOTALS <br />Task Task! ActivitylDescription Number <br />1 Trained LHJ staff will conduct sanitary <br />surveys of small community and non- <br />community Group A water systems <br />identified by the DOH Office of Drinking <br />Water (ODW) Regional Office. <br />See Special Instructions for task activity. <br />Exhibit A, Statements of Work <br />Revised as of November 15,2016 <br />I <br />I <br />CFDA# BARS Master Funding Period Current Change Total <br />Revenue Index (LHJ Use Only) Consideration Increase (+) Consideration <br />Code Code Start Date End Date <br />N/A 346.26.64 2421921C 01101115 12/31117 6,600 2,800 9AOO <br />N/A 346.26.65 2421252C 01/01115 12/31117 6,600 2,800 9,400 <br />N/A 346.26.66 2421921D 01/01115 12/31117 3,400 2,000 5,400 <br />16,600 7,600 24,200 <br />*May Support PHAB Delivera bles/Outcomes Due DatelTime Frame Payment Information <br />StandardslMeasures and/or Amount <br />Provide Final* Sanitary Survey Final Sanitary Survey Upon ODW acceptance <br />Reports to ODW Regional Office. Reports must be received of the Final Sanitary <br />Complete Sanitary Survey Reports by the ODW Regional Survey Report, the LHJ <br />shall include: Office within 30 calendar shall be paid $400 for <br />1. Cover letter identifying days of conducting the each sanitary survey of a I <br />significant deficiencies, sanitary survey. non-community system <br />significant findings, with three or fewer <br />observations, recommendations, connections. <br />and referrals for further ODW <br />follow-up. Upon ODW acceptance <br />2. Completed Small Water System ofthe Final Sanitary <br />checklist. Survey Report, the LHJ <br />3. Updated Water Facilities shall be paid $800 for <br />Inventory (WFI). each sanitary survey of a <br />Page 8 of21 Contract Number C 17114-10