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DOH ProgramName or Tifle: <br />Ianuary 1.2022. <br />SOW Type: Original Revision # (for this SOW) <br />Period of Performance: Ianuary l,.2022through December 31. 2022 <br />Statement of Work Purpose: The purpo <br />community and non-community Group A <br />Revision Purpose: N/A <br />Exhibit A, Statement of Work <br />Template September202 1 <br />Exhibit A <br />Statement of Work <br />Conhact T ermt, 2022-2024 <br />Local Health Jurisdiction Name: Kittitas countv public Health Department <br />Contract Number: CLH3 l0l5 <br />Type of Payment <br />I Reimbunement <br />X Pixed Price <br />Federal Compliance <br />(check if applicable) <br />El rrera (Transparency Act) <br />LJ Research & Development <br />Fundins Source <br />El P"AJ*I ContractorX stut" <br />D other <br />se of this statement of work is to provide funding to the LHJ for conductingsanitary surveys and providing technical assistance to smallwater systems <br />TotaI <br />Allocation <br />J <br />J <br />I <br />0 <br />0 <br />Allocation <br />Change <br />Increase (+) <br />-t <br />3 <br />I <br />0 <br />0 <br />0 <br />Current <br />Allocation <br />0 <br />0 <br />I <br />12t31/22 <br />I <br />LHJ F'unding Period <br />Start Date End Date <br />I <br />0r/0t/22 <br />I <br />BARS <br />Revenue <br />Code <br />346.26.65 <br />346.26 <br />Assistance <br />Listing <br />Number <br />A <br />NiA <br />N/A <br />Masfur <br />fndex <br />Code <br />24249224 <br />TE <br />I <br />DOII Chart of Accounts Master Index Tifle <br />STIR <br />24 SRF .SSASST <br />-LOCALYR <br />Payment Information and./or Arnount <br />Upon ODW acceptanceo f the Final Sanitary Survey <br />Report, the LHJ shall be paid $400 for each sanitary <br />suruey of a nonrommunity system with three or <br />fewer connections. <br />Upon ODW acceptance of the Final Sanitary Survey <br />Report, the LHJ shall be paid $800 for each sanitary <br />survey of a'non+ommunity system with fouror more <br />connections and each community system. <br />Paymentis inclusive of all associatedcostssuch as <br />travel, lodging per diem. <br />*!4yment is authorized upon receipt and acceotance of <br />Due Date/Time tr'rame <br />Final Sanitary Survey <br />Reports must be <br />received bythe ODW <br />RegionalOffice within <br />30 calendar days of <br />conductingthe sanitary <br />survey. <br />Deliverables/Outcomes <br />Provide Final*Sanitary Survey <br />Reports to ODW Regional Office. <br />Complete Sanitary Survey Reports <br />shall include:t. Cover letter identifying <br />significa nt defic iencies, <br />significant findings, observations, <br />recommendations, and referra ls <br />for further ODW follow-up.2. Completed SmallWater System <br />checklist. <br />3. UpdatedWaterFacilities <br />Inventory(WFI). <br />Activity <br />LHJ conduct <br />surveys of small community and non- <br />community Group A water systems <br />identified by the DOH Office of Drinking <br />Water (ODW) Regional Office. <br />See Special Instructions fortask activity. <br />The purpose of this statement ofworkis to <br />provide funding to the LHJ forconducting <br />sanitary surveys and providing technical <br />assistance to small community andnon- <br />A water <br />Task <br /># <br />I <br />Page 1 of4 ContractNumberCLH3 1 0 I 5