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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 />Local Health Jurisdiction Name: Kittitas County Public Health Department <br />Contract Number: CLHl 8249 <br />SOW Type: Original Revision # (for this SOW) <br />Period of Performance: January 1, 2018 through June 30, 2018 <br />Funding Source Federal Compliance l)pe of hymeut • Federal <Select One> (check if applicable) 0 R.eimbwseme,:11 181 State 0 FFATA (Transparency Act) 18] Fixed ~e, <br />D Other D Research & Development <br />Statement of Work Purpose: The purpose of this statement of work is to provide financial support to LHJs implementing local Group B water system programs. <br />Revision Purpose: N/ A <br />Chart of Accounts Program Name or Title CFDA# BARS Master Funding Period Current Change Total <br />Revenue Index (LBJ Use Only) Consideration Increase(+) C onsideration <br />Code Code Start Date End Date <br />GFS -Group B (FO-E) NIA I 334.04.90 24240103 01101118 I 06/30/18 I 0 5 ,000 5.000 <br />TOTALS 0 5,000 5,000 <br />Task *May Support PBAB Memorandum of Payment <br />Task/Activity/Description Deliverables/Outcomes Information and/or Number Standards/Measures Agreement Number Amount <br />1 Implement a full Group B water -An executed joint plan of respoDS1bility (JPR) Reference DOH JPR Lu.mp sum payment <br />system program. with DOH identifying responsibilities of a full #N19411 (See Special Billing <br />GroupB. Requirements) <br />*For Information Only: <br />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 <br />Standard/Measure. More detail on these and/or other Public Health Accreditation Board (PHAB) Standards/Measures that may apply can be found at: <br />htro.:.1/www .ohaboard.ow wp-contenl/uoload.,;,'PH A,B-Standards-and-Mcasures-Ver:s ion-1 .O.odf <br />Program Specific Requirements/Narrative <br />Special Billing Requirements <br />The LHJ shall submit a $5,000 invoice before May 15, 2018. <br />DOB Program Contact DOB Fiscal Contact <br />Dorothy Tibbetts, MS MPH Karena McGovern <br />Eastern Regional Manager DOH Office ofDrinking Wat.er <br />DOH Office of Drinking Water 243 Israel Rd SE <br />16201 E Indiana Ave, Suite 1500 Tumwater, WA 98501 <br />Spokane Valley, WA 99216 Karena.Mcgovem@doh.wa.gov <br />Dorothv.Tibbens@doh.wa.gov (360) 236-3094 <br />(509) 329-2105 <br />Exhibit A, Statements ofWorlc Page 10 of28 Contract Number CLH18249