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Exhibit A <br />Statement of Work <br />Contract Term: 2022-2024 <br />DOH Program Name or Title: Office of Drinking Water Group A Program - Effective <br />January 1, 2022. <br />SOW Type: Origina Revision # (for this SOW) <br />Period of Performance: January 1,2022 through December 31.2022 <br />Local Health Jurisdiction Name: Kittitas County Public Health Department <br />Contract Number: CLH31015 <br />Funding Source Federal Compliance Type of Payment <br />® Federal Contractor (check if applicable) ❑ Reimbursement <br />® State ER FFATA (Transparency Act) ® Fixed Price <br />❑ Other ❑ Research & Develo ment <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: N/A <br />DOH Chart of Accounts Master Index Title <br />Master <br />Index <br />Code <br />Assistance <br />Listing <br />Number <br />BARS <br />Revenue <br />Code <br />LHJ Funding Period <br />Start Date End Date <br />Current <br />Allocation <br />Allocation <br />Change <br />g <br />Increase (+) <br />Total <br />Allocation <br />SANITARY SURVEY FEES (FO -E) SS -STATE <br />24242522 <br />N/A <br />346.26.65 <br />01/01/22 12/31/22 <br />0 <br />3,600 <br />3,600 <br />YR 24 SRF -LOCAL ASST 15%) (FO -E) SS <br />24249224 <br />N/A <br />346.26.64 <br />01/01/22 12/31/22 <br />0 <br />3,600 <br />3,600 <br />YR 24 SRF -LOCAL ASST 15%) (FO -E) TA <br />24249224 <br />N/A <br />346.26.66 <br />01/01/22 12/31/22 <br />0 <br />1,000 <br />1,000 <br />significant deficiencies, <br />conducting the sanitary <br />Upon ODW acceptance of the Final Sanitary Survey <br />See Special Instructions fortask activity. <br />0 <br />0 <br />0 <br />recommendations, and referrals <br />survey of a non -community system with four or more <br />0 <br />0 <br />0 <br />connections and each community system. <br />The purpose of this statement of work is to <br />2. Completed Small Water System <br />0 <br />0 <br />0 <br />TOTALS <br />checklist. <br />Payment is inclusive of all associated costs such as <br />0 <br />8,200 <br />8,200 <br />Task <br />Activity <br />Deliverables/Outcomes <br />Due Date/Time Frame <br />Payment Information and/or Amount <br />1 <br />Trained LHJ staff will conduct sanitary <br />Provide Final* Sanitary Survey <br />Final Sanitary Survey <br />Upon ODW acceptance of the Final Sanitary Survey <br />surveys of small community and non- <br />Reports to ODW Regional Office. <br />Reports must be <br />Report, the LHJ shall be paid $400 for each sanitary <br />community Group A water systems <br />Complete Sanitary Survey Reports <br />received by the ODW <br />survey of a non -community system with three or <br />identified by the DOH Office of Drinking <br />shall include: <br />Regional Office within <br />fewer connections. <br />Water (ODW) Regional Office. <br />1. Cover letter identifying <br />30 calendar days of <br />significant deficiencies, <br />conducting the sanitary <br />Upon ODW acceptance of the Final Sanitary Survey <br />See Special Instructions fortask activity. <br />significant findings, observations, <br />survey. <br />Report, the LHJ shall be paid $800 for each sanitary <br />recommendations, and referrals <br />survey of a non -community system with four or more <br />for further ODW follow-up. <br />connections and each community system. <br />The purpose of this statement of work is to <br />2. Completed Small Water System <br />provide funding to the LHJ for conducting <br />checklist. <br />Payment is inclusive of all associated costs such as <br />sanitary surveys and providing technical <br />3. Updated Water Facilities <br />travel, lodging, per diem. <br />assistance to small community and non- <br />Inventory (WFI). <br />community Group A waters stems. <br />I <br />I <br />I Payment is authorized upon receipt and acceptance of <br />Exhibit A, Statement of Work Page 1 of 4 Contract NumberCLH31015 <br />Template September2021 <br />