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AMENDMENT #3 <br />Exhibit A <br />Statement of Work <br />Contract Term: 2018-2020 <br />DOH Program Name or Title: Office of Drinking Water Group A Program - <br />Effective January l, 2018 <br />SOW Type: Revision Revision # (for this SOW) 1 <br />Period of Performance: January l, 2018 through December 31, 2020 <br />Local Health Jurisdiction Name: Kittitas County Public Health Department <br />Contract Number: CLH18249 <br />Funding Source Federal Compliance Type of Payment <br />~ Federal Contractor (check if applicable) D Reimbursement <br />~ State D FFATA (Transparency Act) ~ Fixed Price <br />D Other D Research & Development <br />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 <br />community and non-community Group A water systems . <br />Revision Purpose: The purpose of this revision is to change end date in Funding Period from 12/31/20 to 12/31/18 and change chart of accounts title and MI for SS and TA <br />Chart of Accounts Program Name or Title <br />Yr 20 SRF -Local Asst (15%_) (FS) ss <br />Sanitary Survey Fees (FO-E) SS-State <br />Yr 20 SRF -Local Asst (15%) (FS) TA <br />Yr 21 SRF -Local Asst (15%) (FS) ss <br />Yr 21 SRF -Local Asst (15%) (FS) TA <br />TOTALS <br />Task Task/Activity/Description Number <br />1 Trained LHJ staff will conduct <br />sanitary surveys of small community <br />and non-community Group A water <br />systems identified by the DOH Office <br />of Drinking Water (ODW) Regional <br />Office. <br />See Special Instructions for task <br />activity. <br />DOH will provide a tablet and GPS <br />unit for the LHJ to 2ather source data <br />Exhibit A, Statements of Work <br />Revised as of May 15, 2018 <br />CFDA# <br />NIA <br />NIA <br />NIA <br />NIA <br />NIA <br />*May Support PHAB <br />Standards/Measures <br />BARS Master Funding Period Current Change Total <br />Revenue Index (LBJ Use Only) Consideration None Consideration <br />Code Code Start Date End Date <br />346.26.64 24139220 01/01/18 12/31/18 2,400 -2 ,400 0 <br />346 .26 .65 24242522 01/01/18 12/31/18 2,400 0 2,400 <br />346.26 .66 24139220 01/01/18 12/31/18 2,000 -2 ,000 0 <br />346.26.64 24139221 01/01/18 12/31/18 0 2,400 2,400 <br />346.26.66 24139221 01/01/18 12/31/18 0 2 ,000 2,000 <br />6,800 0 6,800 <br />Deliverables/Outcomes Due Date/Time Payment Information and/or Amount Frame <br />Provide Final* Sanitary Final Sanitary Survey Upon ODW acceptance of the Final <br />Survey Reports to ODW Reports must be Sanitary Survey Report, the LHJ shall <br />Regional Office. Complete received by the ODW be paid $400 for each sanitary survey of <br />Sanitary Survey Reports shall Regional Office a non-community system with three or <br />include: within 30 calendar fewer connections. <br />1. Cover letter identifying days of conducting <br />significant deficiencies, the sanitary survey. Upon ODW acceptance of the Final <br />significant findings, Sanitary Survey Report, the LHJ shall <br />observations, be paid $800 for each sanitary survey of <br />recommendations, and a non-community system with four or <br />referrals for further more connections and each community <br />ODW follow-up. system. <br />2. Completed Small Water <br />System checklist. Payment is inclusive of all associated <br />3. Updated Water Facilities costs such as travel, lodging, _per diem. <br />Page 6 of 13 Contract Number CLH18249-3