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AMENDMENT #19 <br />Exhibit A, Statements of Work <br />Revised as of January 15, 2021 <br />Page 26 of 30 Contract Number CLH18249-19 <br /> <br /> <br />Exhibit A <br />Statement of Work <br />Contract Term: 2018-2021 <br /> <br />DOH Program Name or Title: Office of Drinking Water Group A Program - <br />Effective January 1, 2018 <br />Local Health Jurisdiction Name: Kittitas County Public Health Department <br />Contract Number: CLH18249 <br />SOW Type: Revision Revision # (for this SOW) 7 Funding Source <br />Federal Contractor <br />State <br />Other <br />Federal Compliance <br />(check if applicable) <br />FFATA (Transparency Act) <br />Research & Development <br />Type of Payment <br />Reimbursement <br />Fixed Price Period of Performance: January 1, 2018 through December 31, 2021 <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 technica l assistance to small <br />community and non-community Group A water systems. <br />Revision Purpose: The purpose of this revision is to extend the Period of Performance thru December 31, 2021, provide Sanitary Survey and Technical Assistance funding in <br />Year 23, revise Special Billing Requirements and Special Instructions, and change DOH Fiscal Contact. <br /> <br /> <br />Chart of Accounts Program Name or Title CFDA # BARS <br />Revenue <br />Code <br />Master <br />Index <br />Code <br />Funding <br />(LHJ Use <br />Start Date <br />Period <br />Only) <br />End Date <br />Current <br />Consideration <br />Change <br />Increase (+) <br />Total <br />Consideration <br />Yr 20 SRF - Local Asst (15%) (FS) SS N/A 346.26.64 24139220 01/01/18 12/31/18 0 0 0 <br />Sanitary Survey Fees (FO-E) SS-State N/A 346.26.65 24242522 01/01/18 12/31/20 9,000 0 9,000 <br />Yr 20 SRF - Local Asst (15%) (FS) TA N/A 346.26.66 24139220 01/01/18 12/31/18 0 0 0 <br />Yr 21 SRF - Local Asst (15%) (FS) SS N/A 346.26.64 24139221 01/01/18 06/30/19 2,400 0 2,400 <br />Yr 21 SRF - Local Asst (15%) (FS) TA N/A 346.26.66 24139221 01/01/18 06/30/19 0 0 0 <br />Yr 22 SRF - Local Asst (15%) (FO-E) SS N/A 346.26.64 24249222 01/01/19 12/31/20 6,600 0 6,600 <br />Yr 22 SRF - Local Asst (15%) (FO-E) TA N/A 346.26.66 24249222 01/01/19 12/31/20 2,000 0 2,000 <br />Yr 23 SRF - Local Asst (15%) (FO-E) SS N/A 346.26.64 24249223 01/01/21 01/31/21 0 10,400 10,400 <br />Yr 23 SRF - Local Asst (15%) (FO-E) TA N/A 346.26.66 24249223 01/01/21 01/31/21 0 2,000 2,000 <br />TOTALS 20,000 12,400 32,400 <br /> <br /> <br />Task <br />Number <br /> <br />Task/Activity/Description *May Support PHAB <br />Standards/Measures <br /> <br />Deliverables/Outcomes Due Date/Time <br />Frame <br /> <br />Payment Information and/or Amount <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 /> Provide Final* Sanitary <br />Survey Reports to ODW <br />Regional Office. Complete <br />Sanitary Survey Reports shall <br />include: <br />1. Cover letter identifying <br />significant deficiencies, <br />Final Sanitary Survey <br />Reports must be <br />received by the ODW <br />Regional Office <br />within 30 calendar <br />days of conducting <br />the sanitary survey. <br />Upon ODW acceptance of the Final <br />Sanitary Survey Report, the LHJ shall <br />be paid $400 for each sanitary survey of <br />a non-community system with three or <br />fewer connections.