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Exhibit A Statement of Work Contract Term: 2015-2017 AMENDMENT #11 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) 5 Funding Source Federal Compliance Type of Payment IZI Federal Contractor (check if applicable) D Reimbursement IZI State D FF A T A (Transparency Act) IZI Fixed Price D Other D 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: The purpose of this revision is to decrease funding 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 (LUJ Use Only) Consideration Decrease (-) Consideration Code Code Start Date End Date Drinking Water Group A -SS N/A 346.26.64 2421921C 01/01115 12/31117 9,400 0 9,400 Drinking Water Group A -SS State N/A 346.26.65 2421252C 01/01115 12/31/17 9,400 0 9~400 Drinking Water Group A -TA N/A 346.26.66 2421921D 01/01115 12/31117 I 5.400 -2 ,400 3,000 TOTALS 24,200 -2,400 21,800 - - Task *May Support PUAB Payment Information Number Tas k/ Activity /Descri ption StandardslMeasures Deliverables/Outcomes Due Date/Time Frame and/or Amount 1 Trained LHJ staff will conduct sanitary Provide Fina1* 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 identified by the DOH Office of Drinking shall include : Office within 30 calendar shall be paid $400 for Water (ODW) Regional Office. I. Cover letter identitying days of conducting the each sanitary survey of a significant deficiencies , sanitary survey . non-community system See Special Instructions for task activity. significant fmdings , with three or fewer observations, recommendations, cormections. and referrals for further ODW 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 I I Inventory (WFI). eaoh ",n;ta'y'survey of a I 4 . Photos of water system with text non-commumty system identitying features with four or more Exhibit A, Statements of Work Revised as of March 15, 2017 Page 3 of 17 Contract Number C 17114-11