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Exhibit A <br />Statement of Work <br />Contract Term: 2018-2020 <br />DOH Program Name or Title: Office of Drinking Water Group B Program- <br />Effective January 1, 2018 <br />SOW Type: Original Revision # (for this SOW) <br />Period of Performance: January 1, 2018 through June 30, 2018 <br />Local Health Jurisdiction Name: Kittitas County Public Health Department <br />Contract Number: CLH18249 <br />Funding Source Federal Compliance Type of Payment o Federal <Select One> (check if applicable) o Reimbursement <br />[8J State D FFATA (Transparency Act) [8J Fixed Price <br />D Other D Research & Development <br />Statement of Work Purpose: The purpose of this statement of work is to provide fmancial support to LHJs implementing local Group B water system programs. <br />Revision Purpose: NI A <br />Chart of Accounts Program Name or Title 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 />GFS -Group B (FO-E) N/A 334.04.90 24240103 01101118 I 06/30/18 0 5,000 5,000 <br />TOTALS 0 5,000 5,000 <br />Task *May Support PHAB Memorandum of Payment <br />Task! Activity/Description Deliverables/Outcomes Information and/or Number StandardslMeasures Agreement Number Amount <br />1 Implement a full Group B water An executed joint plan of responsibility (JPR) Reference DOH JPR Lump sum payment <br />system program. with DOH identifying responsibilities of a full #NI9411 (See Special Billing <br />Group B. Requirements) <br />*For Information Only: <br />Funding is not tied to the revised StandardslMeasures listed here. This information may be helpful in discussions of how program activities might contribute to meeting a <br />StandardlMeasure. More detail on these and/or other Public Health Accreditation Board (PHAB) StandardslMeasures that may apply can be found at: <br />httJj :ll www.p hahoard .o rglwp -eoruent/uploadSfPHAB-Standards-and-Measures -Vim>ion-l.O.pdf <br />Program Specific Reguirements/Narrative <br />Special Billing Requirements <br />The LHJ shall submit a $5,000 invoice before May 15, 2018. <br />DOH Program Contact <br />Dorothy Tibbetts, MS MPH <br />Eastern Regional Manager <br />DOH Office of Drinking Water <br />16201 E Indiana Ave, Suite 1500 <br />Spokane Valley, WA 99216 <br />Dorothy. Tibbetts@doh.wa.gov <br />(509) 329-2105 <br />Exhibit A, Statements of Work <br />DOH Fiscal Contact <br />Karena McGovern <br />DOH Office of Drinking Water <br />243 Israel Rd SE <br />Tumwater, WA 98501 <br />Karena.Mcgovern@doh.wa.gov <br />(360) 236-3094 <br />Page 10 of28 Contract Number CLH18249