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I AMENDMENT #3 Task Task/ Activity/Description *May Support PHAB Deliverables/Outcomes Due Date/Time Payment Information and/or Amount Number Standards/Measures Frame Payment is authorized upon receipt and acceptance of completed TA Report within the 30-day deadline. Late or incomplete reports may not be acce_Qted for payment. 4 LHJ staff performing the activities Prior to attending the Annually LHJ shall be paid mileage, per diem, under tasks 1, 2 and 3 must have training, submit an lodging, and registration costs as completed the mandatory Sanitary "Authorization for Travel approved on the pre-authorization form Survey Training. (Non-Employee)" DOH in accordance with the current rates Form 710-013 to the ODW listed on the OFM Website See Special Instructions for task Program Contact below for htm://www.ofm . wa .!!ov/r~,;o urces/travel activity. approval (to ensure that .asp enough funds are available). *For Information Only: 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 Standard/Measure. More detail on these and/or other Public Health Accreditation Board (PHAB) Standards/Measures that may apply can be found at: hltp://www.phab~ard.org/wo-content/uoloads/PHAB -S tandards-and-Measures-Version-!. 0 .pdf Program Specific Requirements/Narrative Special References (RCWs, WACs, etc) Chapter 246-290 WAC is the set of rules that regulate Group A water systems. By this statement of work, ODW contracts with the LHJ to conduct sanitary surveys (and SP Is, and provide technical assistance) for small community and non-community water systems with groundwater sources. ODW retains responsibility for conducting sanitary surveys (and SPis, and provide technical assistance) for small community and non-community water systems with surface water sources, large water systems, and systems with complex treatment. LHJ staff assigned to perform activities under tasks 1, 2 , and 3 must be trained and approved by ODW prior to performing work. See special instructions under Task 4 , below. Special Billing Requirements The LHJ shall submit quarterly invoices within 30 days following the end of the quarter in which work was completed, noting on the invoice the quarter and year being billed for. Payment cannot exceed a maximum accumulative fee of$4,800 for Task 1, and $2,000 for Task 2, Task 3 and Task 4 combined during the contracting period, to be paid at the rates specified in the Payment Method/ Amount section above. When invoicing for sanitary surveys. bill h alf to BARS Revenue Code 3 46 .2 6 .64 and half to BARS Revenue Code 346 .26.65. When invoicing for Task 1, submit the list ofWS Name, ID#, Amount Billed, Survey Date and Letter Date that you are requesting payment. When invoicing for Task 2-3 , submit the list ofWS Name, ID#, TA Date and description of TA work performed, and Amount Billed. When invoicing for Task 4, submit receipts and the signed pre-authorization form for non-employee travel to the ODW Program Contact below and a signed Al9-1A Invoice Voucher to the DOH Grants Management, billing to BARS Revenue Code 346.26 .66 under Technical Assistance (TA). Special Instructions Task 1 Exhibit A, Statements of Work Revised as of May 15, 2018 Page 8 of 13 Contract Number CLH18249-3