Laserfiche WebLink
Exhibit A <br />Statement of Work <br />Conhact T erm: 2022-2024 <br />DOII ProgramName or Tifle: Office ofDrinking WaterGrouo B Proerams - Effective LocalHealth Jurisdiction NameIatuawl.2022 <br />Period of Performance: Januarv 1.2022 through June 30. 2023 <br />Kittitas County Public Health Deoartment <br />Contract Number: CLH3 101 5 <br />SOW Type: Original Revision # (for this SOW)Type of Payment <br />E Reimbursement <br />X Fixed Price <br />Federal Compliance <br />(check if applicable) <br />n PPefe (fransparency Act) <br />LI Research & Development <br />Funding Source <br />I f.AJ*f <Select one> <br />EI staten otne. <br />StatementofworkPurpose: Thepurposeofthisstatementofwork(sow) istoprovidefinancialsupporttoLHJsimplementinglocalGroupBwatersystemsprograms. <br />Revision Purpose: N/A <br />DoIr Program and Fiscal contact Information for all concon Sows can be found on the DoH Finance Sharepoint site. euestions related to this Sow, or any otherfinance-related inquiry, may be sent to finance@doh.wa.gov. <br />*Forrnformationonly:FundingisnottiedtotherevisedStandards/Measureslistedhere. Thisinformationmaybehelpfulindiscussionsofhowprogramactivitiesmight <br />contnbute to meeting a Standard/Measure. More detail on these and/orother Public Health Accreditation Board (PHAB) Standards/Measures that may apply can be found at:htto://www.phaboard.org/vp-content/uploads/PHAB-Standards-and-Measures-Version-l.0.odf <br />SpecialBillingRequirements: ForJanuaryl,2022-June30,2022,theLHJsha11 submitoneinvoicenotlaterthanJune30,2022andpaymentcannotexceedamaximum <br />cumulative fe e of $25,87 7 . <br />Exhibit A, Statement of Work <br />Template September202l Page I of I gontractNumberclH3l0l4 <br />Total <br />Allocation <br />25,877 <br />0 <br />0 <br />0 <br />0 <br />7 <br />Allocation <br />Change <br />lncrease (+) <br />25 7 <br />0 <br />0 <br />0 <br />0 <br />77 <br />Current <br />Allocation <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />LIIJ Funding Period <br />Start Date End Date <br />01 t/22 <br />BARS <br />Revenue <br />Code <br />3 <br />Assistance <br />Listing <br />Number <br />Master <br />Index <br />Code <br />24240t03 <br />DOH Chart of Accounts Master Index Title <br />B <br />TOTALS <br />Payment Information <br />and/or Amount <br />Lump sum payment (See <br />Special Billing <br />Requirements) <br />Due Date/Time <br />Frame <br />January 1,2022 <br />thru June 30,2022 <br />Deliverables/Outco mes <br />An executed Memorandum of Agreement (MOA) with <br />DOH identifying responsibilities of a full Group B <br />progam thrqugh a LocalOrdinance. <br />Activity <br />Implement a Group B water <br />Loca I Ordinance. Reference <br />system program through a <br />DOH MOA #CLH23577 <br />Task <br /># <br />1