HomeMy WebLinkAboutDoc 693 - IGA - OHA - public water systemsDeschutes County Board of Commissioners
1300 NW Wall St., Suite 200, Bend, OR 97701-1960
(541) 388-6570 -Fax (541) 385-3202 -www.deschutes.org
AGENDA REQUEST & STAFF REPORT
For Board Business Meeting of December 19,2011
DATE: December 9, 2011
FROM: Nancy England, Contract Specialist, Deschutes County Health Services, 322-7516
TITLE OF AGENDA ITEM:
Consideration of Board Signature of Document #2011-693, Intergovernmental Agreement #136939
between the Local Public Health Department and the Oregon Health Authority for year 2011-2013.
PUBLIC HEARING ON THIS DATE? No.
BACKGROUND AND POLICY IMPLICATIONS:
The Oregon Health Authority's goal is to work in partnership with local environmental health
departments to provide services to public water systems that result in reduced health risk and
increased compliance with drinking water monitoring and maximum contaminant level
requirements.
The drinking water program includes investigation of occurrences of waterborne illness, drinking
water contamination events, response to spills, emergencies, and inspection of water system
facilities. The drinking water program includes reporting of data to the Oregon Health Authority
necessary for program management and to meet federal Environmental Protection Agency (EPA)
Safe Drinking Water Act program requirements. These services include sanitary surveys, follow up
on required water samplings, consultation and public education.
FISCAL IMPLICATIONS:
Maximum funding reimbursement for specific Program Elements for year 11-13 is $164,259.
RECOMMENDATION & ACTION REQUESTED:
Approval and signature of Document #2011-693, Intergovernmental Agreement #136939 between the
Local Public Health Dept. and the Oregon Health Authority is requested.
ATTENDANCE: Eric Mone, Environmental Health Supervisor
DlsrRIBUTION OF DOCUMENTS:
Fax: 1. Contractor Data and Certification including insurance (page 3); 2. Signature page
sign and date the signature page (page 5); 3. Document Return Statement to Connie Thies,
503-373-7889, original to Nancy England, Health Services Department.
DESCHUTES COUNTY DOCUMENT SUMMARY
(NOTE: ThIs form is required to be submitted with All contracts and other agreements. regardlees of wh~Itte document is to be
on a Board agenda or can be signed by the County Administrator or Department Director. If Itte document 18 to be on a Board
agenda. the Agenda Request Form 18 al80 required. If Ittis form 18 not included with the document, the document wiI be returned to
the Department. Please submit documents to Itte Board Secretary for tracking purposes. and not direcUy to Legal Counsel, the
County Administrator or the Commissioners. In addition to submitting this form with your documents, please submit this form
electronically to the Board Secretary.)
Please complete aft sections above the OffIcIal Review line.
Date: I November 28, 2011 I
Department: I Health Services, Environmental Health
Contractor/Supplier/Consultant Name: I State of Oregon, Oregon Health Authorit}1
Contractor Contact: I Thomas Mitchell I Contractor Phone #: I 971-673-0417
Type of Document: Intergovernmental Agreement #136939
I Goods and/or Services: The Oregon Health Authority's goal is to work in partnership
with local environmental health departments to provide services to public water systems
that result in reduced health risk and increased compliance with drinking water
monitoring and maximum contaminant level requirements.
Background & History:
The Oregon Health Authority's primary responsibilities include rulemaking, oversight of
the field inspection system, technical assistance, training, and education. They also
oversee the Safe Drinking Water Program.
The drinking water program includes investigation of occurrences of waterborne illness,
drinking water contamination events, response to spills, emergencies, and inspection of
I water system facilities. The drinking water program includes reporting of data to the
Oregon Health Authority necessary for program management and to meet federal i Environmental Protection Agency (EPA) Safe Drinking Water Act program
I requirements. These services include sanitary surveys, follow up on required water
samplings, consultation and public education.
Agreement Starting Date: I October 1, 2011 1 Ending Date: 1 June 30, 2013
Annual ValuefTotai Payment: I Maximum compensation is $164,259.1 1
[81 Insurance Certificate Receiied (chick box)
Insurance Expiration Date: N/A
Check all that apply: o RFP, Solicitation or Bid Process o Informal quotes «$150K)
[81 Exempt from RFP, Solicitation or Bid Process (specify -see DCC §2.37)
I
Funding Source: (Included in current budget? [81 Yes 0 No
If No, has budget amendment been submitted? 0 Yes 0 No
Is this a Grant Agreement providing revenue to the County? 0 Yes [81 No
Special conditions attached to this grant: D
Deadlines for reporting to the grantor: 1'--_--'
If a new FTE will be hired with grant funds, confirm that Personnel has been notified that
it is a grant-funded position so that this will be noted in the offer letter: 0 Yes 0 No
Contact information for the person responsible for grant compliance: Name:
Phone#:D
Departmental Contact and ntle: I Nancy England, Contract Specialist
Phone #: I 541-322-7516 I
Deparm-t Director Approval: ~,~Ij(yYtV
Signature Date
Distribution of Document: Fax: 1. Contractor Data and Certification including
insurance (page 3); 2. Signature page -sign and date the signature page (page 5); 3.
Document Return Statement to Connie Thies, 503-373-7889, original to Nancy England,
Health Services Department.
D
Official Review:
County Signature Required (check one): ij;] BOCC 0 Department Director (if <$25K)
o Administrator (if >~5K but ~150K; if >$150K, BOCC Order No. )
legal Review 701hiL rP£ Date /? -(' -II
Document Number =20:..1:....:1~-6=9::.::3:...-______
11129/2011
oregonlth
ea .
----Authoritv
Agreement Number 136939
State of Oregon
Intergovernmental Agreement
In compliance with the Americans with Disabilities Act, this document is
available in alternate formats such as Braille, large print, audio recordings, Web
based communications and other electronic formats. To request an alternate
format, please send an e-mail to dhsalt@state.or.us or call 503-378-3486 (voice)
or 503-378-3523 (TTY) to arrange for the alternative format.
This Agreement is between the State of Oregon, acting by and through the Oregon Health
Authority, hereinafter referred to as "OHA," and
Deschutes County
Health Services
2577 NE Courtney Drive
Bend OR 97701
Attn: Tom Kuhn
541-322-7410
thomask@co.deschutes.or.us
hereinafter referred to as "County" the entity designated, pursuant to ORS 431.375(2), as the
Local Public Health Authority ("LPHA") for Deschutes County.
Work to be performed under this Agreement relates principally to the OHA's
Public Health Division
Office of Environmental Public Health
Drinking Water Program
800 NE Oregon St.
Portland, OR 97232
Attn: Thomas Mitchell
Phone: 971-673-0417
Fax: 971-673-0694
Email: thomas.j.mitchell@state.or.us
~~'tbfl
LEGAL COUNSEL
DC':'2Q11-693
....
l. Effective Date and Duration
This Agreement shall become effective on October 1, 2011 when this Agreement has
been fully executed by every party and, when required, approved by Department of
Justice. Unless extended or terminated earlier in accordance with its terms, this
Agreement shall terminate on June 30, 2013. Agreement termination or expiration shall
not extinguish or prejudice either party's right to enforce this Agreement with respect to
any default by the other party that has not been cured.
2. Agreement Documents
a. This Agreement without exhibits consists of:
Exhibit A Part 1: Definitions
Exhibit A Part 2: Statement of Work
Exhibit A Part 3: Payment and Financial Reporting
Exhibit A Part 4: Special Terms and Conditions
Exhibit B: Standard Terms and Conditions
Exhibit C: Subcontractor Insurance Requirements
Exhibit D: Required Federal Terms and Conditions
Attachment 1: Water System Survey Forms
Attachment 2: Water System Information Form
Attachment 3: Entry Structure Diagram Form
Attachment 4: Source Info Form
Attachment 5: Contact Report Form
Attachment 6: Emergency Response Form
Attachment 7: Checklist for Water System Plan Review
Attachment 8: Chemical Monitoring Schedule Change Form
This Agreement constitutes the entire agreement between the parties on the
subject matter in it. There are no understandings, agreements or representations,
oral or written, regarding this Agreement that are not specified in it.
b. In the event of a conflict between two or more of the documents comprising this
Agreement, the language in the document with the highest precedence shall
control. The precedence of each of the documents comprising this Agreement is as
follows, listed from highest precedence to lowest precedence: this Agreement
without Exhibits, Exhibits D, A, B, and C.
c. For purposes of this Agreement, "Work" means specific work or services to be
perfonned by County as set forth in Exhibit A.
3. Consideration
a. The maximum not-to-exceed amount payable to County under this Agreement,
which includes any allowable expenses, is $164,259.00. OHA will not pay County
any amount in excess of the not-to-exceed amount for completing the Work, and
will not pay for Work until this Agreement has been signed by all parties.
b. OHA will pay only for completed Work under this Agreement, and may make
interim payments as provided for in Exhibit A.
OHA Agreement # J 36931-0, vkd Page 2 of65
OHA IGA County Template reviewed August 25, 2011
4. Vendor Or Sub-Recipient Determination
In accordance with the State Controller's Oregon Accounting Manual, policy
30.40.00.102, OHA's detennination is that:
~County is a sub-recipient; OR County is a vendor.
Catalog of Federal Domestic Assistance (CFDA) #(s) of federal funds to be paid through
this Agreement:
100% fed. pass-Vendor/ Service/
Federal funding source: thru grant? CFDA #: subrecipient: program element:
EPA Primary xD Ves 0
No
66.432 Subrecipient Required Services USi~
Base Funds
SRF State Prog. Mgt. XDVesD
No
66.468 Subrecipient Required Services Using
Invoiced Funds
BvesDNo
Yes D No
5. County Data and Certification
a. County shall provide County's information set forth below. This infonnation is
requested pursuant to ORS 305.385.
Please print or type the following information.
Name (exactly as filed with the IRS) ];:>e-sc.ht.dCS (.N.,..A.f'\"'"'1
Address, City, State & ZIP j:?cD N\.U Wall Siro:.t
E-mail address:~~f2desc.h(.cH:S.0('8-"'1----------
Telephone: ~I) 2ll--.,1.(10 Facsimile: (HI) 5Z" ---'':f'->o'''-'(p'''''-'''''5c--___
Federal Employer Identification Number:_q-'-=2>_-......;Gz......:;q....)'""2;.;.:~:.-..:&J_;;:{_________
Proof of Insurance:
Workers Compensation -Insurance Company Se,1( -\o">:.v.(c.d.
Policy # \J/f\ Expiration Date: _-=.fi~A,--___
The above infonnation must be provided prior to Agreement approval. County
shall provide proof of Insurance upon request by OHA or OHA designee.
b. Certification. By signature on this Agreement, the undersigned hereby certifies
under penalty of perjury that:
(1) The undersigned is authorized to act on behalf of County and that County
is, to the best of the undersigned's knowledge, not in violation of any
Oregon Tax Laws. For purposes of this certification, "Oregon Tax Laws"
means a state tax imposed by ORS 320.005 to 320.150 and 403.200 to
403.250 and ORS chapters 118,314,316,317,318,321 and 323 and the
OHA Agreement # 136931-0, vkd Page 3 of65
OHA JOA County Template reviewed August 25,2011
elderly rental assistance program under ORS 3lO.630 to 3lO.706 and local
taxes administered by the Department of Revenue under ORS 305.620;
(2) The data information in Section 5.a. is County's true and accurate
information;
(3) To the best of the undersigned's knowledge, County has not discriminated
against and will not discriminate against minority, women or emerging
small business enterprises certified under ORS 200.055 in obtaining any
required subcontracts;
(4) County and County's employees and agents are not included on the list
titled "Specially Designated Nationals and Blocked Persons" maintained
by the Office of Foreign Assets Control of the United States Department
of the Treasury and currently found at:
http://www.treas.govI offices/enforcement/ofac/sdnlt II sdn.pdf;
(5) County is not listed on the non-procurement portion of the General Service
Administration's "List of Parties Excluded from Federal procurement or
Nonprocurement Programs" found at: http://www.epls.gov/; and
(6) County is not subject to backup withholding because:
(a) County is exempt from backup withholding;
(b) County has not been notified by the IRS that County is subject to
backup withholding as a result of a failure to report all interest or
dividends; or
(c) The IRS has notified County that County is no longer subject to
backup withholding.
c. County is required to provide its Federal Employer Identification Number (FEIN).
By County's signature on this Agreement, County hereby certifies that the FEIN
provided to OHA is true and accurate. If this information changes, County is also
required to provide OHA with the new FEIN within 10 days.
OHA Agreement # 136931-0, vkd Page 4 of65
OHA IGA County Template reviewed August 25,2011
Deparliment: of Admlnlatrative .rvicee
Erik Kropp, Deputy County Administrator
13CXl NoN Wei at. Suite 200 • Bend, D-egon 97701
(541) 3B&-e584 • FAX (541] 385-3202
WWIII.descht&as.O".U8
March 4, 2011
To whom it may concern,
The purpose of this letter is to certify that Deschutes County, Oregon, is and has been since at least
1990, a self..fnsured entity pursuant to ORS 30.282 and has established a self-insurance fund for liability
arising out of any tort claims against any of its programs, officers, agents. employees and volunteers
acting within the scope of their employment during this period. This coverage is applicable under any
Deschutes County agreement.
Sincerely,
Erik Kropp
Deputy County Administrator
EnJumcing the l.i.ves ofCitizens by Delivering Quality Seroices in II Cost-Effective Manner
Certificate of Self-Insurance
This Is tD certify that Deschutes county, Oregon Is a self-Insured entity pursuant
tD ORS 30.282 and has estabflshed a self-insured .fund against liability and
property damage arising out of any tort dalms against itS programs, officers,
agents, employees and volunteers acting within the soope of their employment.
This coverage is applicable under any Deschutes County agreement.
Please refer inquiries to:
Deschutes County Risk Management
Erik Kropp, RIsk Manager (541) 388-6584
Judy Sumners, aalms CoordfnatDr (541) 385-1749
Ken Hanns, Loss PreventIon Spedallst (541) 617--4747
1300 NW Wall St., Ste. 200, Bend, OR 97701
Effective Date 12/17/08, no expiration
DHS SHARED SERVICES
Oftice of Contracts and Procurement
John A. Kitzhaber. MD, Governor 250 Winter St NE, Room 306
Salem, OR 97301
Voice: (503) 945-5818
FAX: (503) 373-7889
DOCUMENT RETURN STATEMENT
November 16, 2011
Re: Document #: 138939, hereinafter referred to as "Document."
Please complete the following statement and return it along with the completed
signature page and the Contractor Data and Certification page and/or Contractor Tax
Identification Information form (if applicable).
Important: If you have any questions or find errors in the above referenced Document,
please contact the contract specialist, Vincent Dunn at (503) 945-6194.
(Name) (Title)
received a copy of the above referenced Document, between the State of Oregon,
acting by and through the Department of Human Services, the Oregon Health Authority,
and Deschutes County, bye-mail from Connie Thies on November 16,2011.
On _______, I signed the electronically transmitted Document without
(Date)
change. I am returning the completed signature page and Contractor Data and
Certification page and/or Contractor Tax Identification Information form (if applicable)
with this Document Return Statement.
(AuthOrizing Signature) (Date)
EACH PARTY, BY EXECUTION OF THIS AGREEMENT, HEREBY
ACKNOWLEDGES THAT IT HAS READ THIS AGREEMENT, UNDERSTANDS IT,
AND AGREES TO BE BOUND BY ITS TERMS AND CONDITIONS.
County: Deschutes County
By:
Authorized Signature Title Date
State of Oregon acting by and through the Oregon Health Authority pursuant to ORS 190
By:
Authorized Signature Title Date
Approved for Legal Sufficiency:
Approved by email per ORS 291.047 by Stephanie Smythe
Assistant Attorney General
November 9,2011
Date
Program Office Review:
Approved via email
Tom Mitchell
October 25,2011
Date
Office of Contracts and Procurement Review:
Vincent Dunn, Contract Specialist Date
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OHA Agreement #136931-0, vkd Page 5 of65
OHA IGA County Template reviewed August 25, 2011
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EXHIBIT A
Part 1
Definitions
As used in this Agreement, the following words and phrases shall have the indicated meanings.
Certain additional words and phrases may be defined elsewhere in the Agreement in relation to a
specific topic or context. When a word or phrase is defined elsewhere in this Agreement, the word or
phrase shall not necessarily have the ascribed meaning in any part of the Agreement other than the
specific subject area or context in which it is defined.
The following definitions are established for the purposes of interpreting this Intergovernmental
Agreement and for performing the Work required under this Agreement, as set forth in Exhibit A,
Part 2, Statement of Work:
1. Base Funds: Funds used for required program services that build capacity to respond to
emergencies, take independent enforcement actions, maintain access via computer to OHA's
computerized drinking water system database (SDWIS), and to provide regulatory assistance.
2. Community Water System: A public water system that has 15 or more service cOlll1ections
used by year-round residents, or that regularly serves 25 or more year-round residents.
3. Ground water: Water obtained from below the ground surface.
4. Invoiced Funds: Funds used for specific water system related services, which require the
submission of an invoice in order to be paid.
5. Major Monitoring or Reporting (M/R) Violation: Major Monitoring or Reporting
violations occur when a public water system fails to take any routine samples for a particular
contaminant or report any treatment performance data during a compliance period, or fails to
take any repeat samples following a coliform positive routine or where the public water
system has failed to report the results of analyses to OHA-for a compliance period. An M/R
violation is classified as major ifOHA or its agent receives no monitoring report or receives
a report indicating that no monitoring was conducted.
6. Maximum Contaminant Level (MCL) Violation: MCL violations occur when a public
water system's water quality test results demonstrate a level of a contaminant that is greater
than the established Maximum Contaminant Level.
7. Minor Monitoring or Reporting (M/R) Violation: Minor Monitoring or Reporting
violations occur when a public water system takes some but not all ofthe routine samples for
a particular contaminant or collects partial treatment perfonnance data or insufficient
numbers of repeat samples following a coliform positive routine sample during a compliance
period, and reports those partial results to OHA or its agent.
8. Non-EPA Water System: A public water system serving 4-14 connections or 10-24 people
at least 60 days per year (also known as a "non-public" water system by EPA).
OHA Agreement # 136931-0, vkd Page 6 of65
OHA lGA County Template reviewed August 25, 201)
9. Nontransient Noncommunity Water System (NTNCWS): A public water system that is
not a Community Water System and that regularly serves at least 25 ofthe same persons over
6 months per year.
10. OHA: The Oregon Health Authority
11. Priority Noncomplier (PNC): Water systems with system scores of II points or more.
12. Professional Engineer (PE): A person currently registered as a Professional Engineer by the
Oregon State Board of Examiners for Engineering and Land Surveying.
13. Registered Environmental Health Specialist (REHS): A person currently registered as an
Environmental Health Specialist by the Oregon Environmental Health Registration Board.
14. Regulated Contaminants: Drinking water contaminants for which Maximum Contaminant
Levels or Water Treatment Performance Levels have been established under OAR 333-061.
15. SDWIS: OHA's computerized safe drinking water information system database.
16. System Score: A point-based value, based on unaddressed violations for monitoring periods
ending within the last five (5) years, for assessing a water system's level of compliance.
17. Transient Noncommunity Water Systems (TN CWS): A public water system that serves a
transient population of 25 or more persons.
18. Trihalomethanes (THMs): By-products of chlorine disinfection.
19. USEPA or EPA: The US Environmental Protection Agency.
20. Water Quality Alerts: A report generated by the SDWIS data system containing a single
water quality sample result from a public water system that exceeds one-half ofthe MCL for
inorganic or radiological contaminants, or any positive detection of a microbiological or
organic contaminant or any exceedance of lead or copper action levels.
21. Water System Information Form: A report form to update information on a public water
system for the purpose of maintaining a computer database inventory record that is current,
accurate, and complete.
22. Water System Survey: A comprehensive on-site evaluation of a public water system carried
out by County to identify and recommend corrective action to prevent a potentially adverse
effect on the quality of drinking water provided to the public.
23. Water Treatment Performance Level Violation: Water treatment performance violations
occur when a public water system fails to meet established minimum treatment performance
levels during a compliance period.
OHA Agreement #136931-0, vkd Page 7 of65
OHA IGA County Template reviewed August 25, 2011
EXHIBIT A
Part 2
Statement of Work
1. Purpose of the Drinking Water Program. The purpose of the drinking water program is to
provide services to public water systems that result in reduced health risk and increased
compliance with drinking water monitoring and maximum contaminant level requirements.
The drinking water program includes investigation of occurrences of waterborne illness,
drinking water contamination events, response to spills, emergencies, and inspection ofwater
system facilities. The drinking water program includes reporting of data to OHA necessary
for program management and to meet federal EPA Safe Drinking Water Act program
requirements.
a. Agreement funds are intended to enable County to assume primary responsibility for the
quality of drinking water provided by most of the public water systems located within
County's jurisdiction. The work described herein is designed to meet the following EPA
National Drinking Water Objective by 2015:
"91 % of the population served by community water systems will receive
water that meets all applicable health-based drinking water standards
during the year; and 90% of the community water systems will provide
water that meets all applicable health-based drinking water standards
during the year."
b. Public drinking water systems covered in this Agreement include community water
systems, nontransient noncommunity water systems, transient noncommunity water
systems, and non-EPA water systems serving 3,300 or fewer people and using ground
water sources only.
c. Agencies are responsible for public water systems that purchase their water from other
public water suppliers when the purchasing systems serve 3,300 or fewer people.
2. Description of Services, Staffing and Documentation/Reporting Requirements, and
Performance Measures.
a. Service Guidelines and Activities Allowed under the Drinking Water Program.
Work included in this Agreement includes all activities for EPA water systems, as well as
those activities specifically listed for non-EPA systems.
(1.) Required Program Services Using Base Funds: The following required program
services are supported by Base Funds, which are used to build program capacity to
undertake the following services:
(a.) Emergency Response: County shall develop, maintain, and carry out a
response plan for public water system emergencies, including disease
outbreaks, spills, operational failures, and water system contamination.
County shall notify OHA in a timely manner of emergencies that may affect
OHA Agreement # 136931-0, vkd Page 80f65
OHA IGA County Template reviewed August 25, 2011
drinking water supplies. [Citations: ORS Chapter 448, Water Systems;
State/EP A Agreement (FY 0598)]
(b.) Independent Enforcement Actions: County shall take independent
enforcement actions against OHA-licensed facilities that are also public water
systems as covered under the following OARs: 333-029, 333-030, 333-031,
333-039,333-060,333-062,333-150,333-162, and 333-170. County shall
report independent enforcement actions taken and water system status to
OHA using the documentation and reporting requirements specified in this
Agreement. [Citations: ORS Chapter 448, Water Systems; 40 CFR, Chapter I,
Part 142 National Primary Drinking Water Regulations Implementation.
Subpart B, primary enforcement responsibility. (EPA Primacy Regulations)]
(c.) Computerized Drinking Water System Data Base: County shall maintain
access via computer to 0 HA's computerized safe drinking water infonnation
system database (SDWIS). Access via computer to OHA's computerized
drinking water system database is considered essential to carry out the
program effectively. County shall make timely changes to OHA's SDWIS
computer database inventory records ofpublic water systems to keep OHA's
records current. [Citations: ORS Chapter 448, Water Systems; 40 CFR,
Chapter I, Part 142 National Primary Drinking Water Regulations
Implementation. Subpart B, primary enforcement responsibility. (EPA
Primacy Regulations)]
(d.) Regulatory Assistance: County shall provide regulatory assistance in
response to requests from water system operators for infonnation on and
interpretation of regulatory requirements. County shall respond to water
system complaints received as appropriate or as requested by OHA.
[Citations: ORS Chapter 448, Water Systems; 40 CFR, Chapter I, Part 142
National Primary Drinking Water Regulations Implementation. Subpart B,
primary enforcement responsibility. (EPA Primacy Regulations)]
(2.) Required Program Services Using Invoiced Funds: The following required
program activities are supported by Invoiced Funds:
(a.) Investigation of Water Quality Alerts: County shall investigate all water
quality alerts for detections of regulated contaminants at community,
nontransient noncommunity, transient noncommunity, and non-EPA water
systems. County shall consult with and provide advice to the subject water
system operator on appropriate actions to ensure that follow-up sampling is
completed and to ensure that any con finned water quality violations are
corrected or resolved. County shall provide advice to the subject water system
operator on the correct method for issuing public notification and/or advisory
to users on protective action as necessary or as requested by OHA. County
may submit one contact report for multiple alerts for the same contaminant.
[Citations: ORS Chapter 448, Water Systems; 40 CFR, Chapter I, Part 142
OHA Agreement # 136931-0, vkd Page 9 of65
OHA IGA County Template reviewed August 25, 2011
National Primary Drinking Water Regulations hnplementation. SUbpart B,
primary enforcement responsibility. (EPA Primacy Regulations)]
(b.) Resolution of Priority Noncompliers (PNC): County shall periodically (at
least monthly) review PNC status of all water systems and shall contact and
provide assistance to community, nontransient noncommunity, and transient
noncommunity water systems that are priority noncompliers (PNCs) as
follows:
i. When County is notified by OHA that a water system is designated as a
PNC by OHA, County shall take the following actions:
(a.) Contact the water supplier and discuss any unaddressed violations
with emphasis on the MCL violations, determine the reasons for
all aspects of noncompliance, and inform the water supplier on
ways to correct the noncompliance. Confirm that database
information is current and accurate on ownership and water
system classification.
(b.) Advise the owner/operator to carry out public notification as
required.
(c.) Submit public notices received and contact reports on County
follow-up actions to OHA.
ii. Periodically monitor PNC systems to ensure they are making adequate
progress on returning to compliance. A PNC is considered resolved when
its system score drops below 11 points and all MCL violations have been
addressed.
iii. County shall review all persistent PNCs at five (5) months after being
designated as a PNC to determine if the water system can be returned
to compliance within three (3) months.
(a.) If the water system can be returned to compliance within three
(3) months, County shall submit a contact report to OHA with a
draft compliance schedule listing corrective actions required and
a proposed deadline for each action. County shall follow up to
ensure corrective actions are implemented.
(b.) If it is determined the water system cannot be returned to
compliance within three (3) months, County shall prepare and
submit to OHA a written request for a formal enforcement action,
including County's evaluation of the reasons for noncompliance
by the water supplier. The request shall include the current
owner's name and address, a draft compliance schedule listing
corrective actions required, and a proposed deadline for each
action. County shall distribute a copy of the request to the
person(s) responsible for the subject water system's operation to
OHA Agreement # 136931-0, vkd Page 10 of65
OHA lGA County Template reviewed August 25, 2011
I
ensure that person's understanding of the required corrective
actions.
[Citations: ORS Chapter 448, Water Systems; 40 CFR, Chapter I, Part
142 National Primary Drinking Water Regulations Implementation.
Subpart B, primary enforcement responsibility (EPA Primacy
Regulations) ]
(c.) Enforcement Action Tracking and Follow-up: For both EPA and non-EPA
systems, after OHA issues an enforcement action, County shall monitor the
corrective action schedule contained in the action, and verify completion of
each corrective action by the water supplier. County shall document all
contacts and verifications and submit documentation to the OHA. County
shall document any failure by the water supplier to meet any correction date
and notify the OHA within 30 days. County shall notify OHA when all
corrections are complete and submit the notice within 30 days. [Citations:
ORS Chapter 448, Water Systems; 40 CFR, Chapter I, Part 142 National
Primary Drinking Water Regulations Implementation. Subpart B, primary
enforcement responsibility. (EPA Primacy Regulations)]
(d.) Water System Surveys: County shall conduct a survey of each community
water system within County's jurisdiction every three (3) years, or as
otherwise scheduled by OHA; and each nontransient noncommunity and
transient noncommunity water system within County's jurisdiction every five
(5) years or as otherwise scheduled by OHA. A water system survey must
include the source of a public water system, the water intake, treatment
system, storage and distribution facilities, operation and maintenance, water
system records, and compliance with applicable drinking water regulations.
[Citations: ORS Chapter 448, Water Systems; OAR 333-061-0076, 40 CFR,
Chapter I, Part 142 National Primary Drinking Water Regulations
Implementation. Subpart B, primary enforcement responsibility (EPA
Primacy Regulations)].
(e.) County shall use the following procedure for conducting a Water System
Survey:
i. Contact the subject public water system owner/operator to schedule an
appointment and explain the information required to complete the water
system survey.
ii. Review the subject public water system file information, water quality
history, and data base inventory information.
iii. Conduct an on-site review of the water system source, treatment, storage,
and distribution facilities; review its operation, management, and
compliance with regulations; and determine deficiencies, if any, that
could result in unsafe drinking water.
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(a.) Complete water system survey forms.
(b.) Collect coliform sample(s) at County's discretion or as requested
byOHA.
(c.) Verbally inform the owner and/or operator of the subject public
water system deficiencies, required and recommended corrective
actions, and corrective action time lines.
(d.) Complete a Water System Information Form for each public
water system survey completed showing all changes needed to
make data base inventory information complete and accurate.
iv. Verify that water system survey and Water System Information Form are
complete.
v. Prepare cover letter that contains the requirements for the subject public
water system and the required and recommended corrective actions and
time lines for identified water system deficiencies.
vi. Mail cover letter, water system survey report, Water System Infonnation
Form, and any coliform sample resu1t(s) to the subject public water
system.
vii. Submit the cover letter, water system survey report, Water System
Information Form, and any coliform sample result(s) to OHA.
(f.) Emergency Response Plan Development Assistance: County shall assist
water suppliers to complete their Emergency Response Plans and ensure that
completed plans meet OHA standards. [Citations: ORS 448.160 Emergency
Plans; OAR 333-061-0064.]
(g.) Resolution of Monitoring and Reporting Violations: County shall contact
and provide assistance at community, nontransient noncommunity, and
transient noncommunity water systems to resolve (return to compliance)
violations for bacteriological, chemical, and radiological monitoring and
reporting violations and other monitoring or reporting violations as
detennined by OHA. Violation responses shall be prioritized according to
water system's classification, system score, and violation severity. [Citations:
ORS Chapter 448, Water Systems].
i. Contact the water supplier, determine the reasons for the noncompliance,
consult with and provide advice to the subject water system operator on
appropriate actions to ensure that violations are corrected in a timely
manner.
ii. Submit contact reports to OHA regarding follow-up actions to assist
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system in resolving (returning to compliance) the violations. County may
submit a single contact report for multiple violations for the same
contaminant when making contacts with the water system and for
resolutions (return to compliance).
(h.) Inventory and Documentation of New Water Systems County shall
inventory existing water systems that are not in the OHA inventory as they
are discovered, including non-EPA systems, using the forms designated by
OHA. County shall provide the documentation to OHA within 60 days of
identification of an uninventoried water system. Alternatively, County may
perform a water system survey to collect the required inventory information,
rather than submitting the forms designated by OHA. [Citation: ORS Chapter
448, Water Systems].
(i.) Follow-Up on Deficiencies on Water System Surveys: County shall follow
up on significant deficiencies and rule violations between surveys on
community, nontransient noncommunity, and transient noncommunity water
systems to verifY that all deficiencies have been corrected. After deficiencies
are corrected, County shall prepare a list of the deficiencies and the dates of
correction and submit to OHA; or, if all deficiencies are not corrected,
County shall ensure the water system has an approved corrective action plan
submitted to OHA to correct all deficiencies, per OAR 333-061-0076 (6)(b),
(7), (8). Deficiencies include those currently defined in the OHA-Drinking
Water Program publication titled Water System Survey Reference Manual
(October 2009). On site-visits are required to document corrections to a water
system's physical plant. [Citations: ORS Chapter 448, Water Systems; OAR
333-061-0076, OAR 333-061-0032(6),40 CFR, Chapter I, Part 142 National
Primary Drinking Water Regulations Implementation. Subpart B, primary
enforcement responsibility (EPA Primacy Regulations)].
(3.) Supplemental Program Services using Invoiced Funds: In order for County to be
eligible for payment for supplemental services: (1) Required Program Services using
Invoiced Funds must be completed and current; (2) County must have a record of
responding promptly to water quality alerts to OHA's satisfaction; (3) County must
demonstrate that enforcement actions and PNCs have been resolved or adequate
progress has been made towards resolution; and (4) County must demonstrate that
water system surveys are conducted on the appropriate schedule.
(a.) Engineering Plan Review Inspections: County may inspect, at the request
of OHA, construction or major modifications of public water systems to
determine conformance to engineering plans reviewed and approved by the
OHA. Inspections must consist of an on-site visit or visits to verifY
construction is completed in accordance with the approved plans. County
shall document in outline form the facilities checked and any differences
between the constructed facilities and the approved plans. The scope of the
inspection may include but is not limited to: new water sources, treatment
facilities, storage reservoirs, and water mains. Inspections shall be completed
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and documentation forwarded to OHA within 30 days of receipt of the
inspection request. [Citations: ORS Chapter 448, Water Systems; 40 CFR,
Chapter I, Part 142 National Primary Drinking Water Regulations
Implementation. Subpart B, primary enforcement responsibility (EPA
Primacy Regulations)].
(b.) Customized and Negotiated Work: County may conduct such customized
and negotiated work as required or requested by OHA to maintain safe and
efficient public water system operations. County shall prepare and submit for
OHA review and approval a proposal for the customized and negotiated work
including a detailed task list and a listing of expected outcomes. County's
task list must include the cost of each task. OHA must approve the proposal
for customized and negotiated work including OHA's payment to County
prior to County performing such work. [Citations: ORS Chapter 448, Water
Systems; 40 CFR, Chapter I, Part 142 National Primary Drinking Water
Regulations Implementation. Subpart B, primary enforcement responsibility
(EPA Primacy Regulations)].
(4.) Work Priorities: County shall prioritize all work according to the relative health risk
involved and according to system classification with community water systems
receiving the highest priority.
b. Staffing Requirements and Qualifications, and Documentation and Reporting
Requirements.
(1.) County shall develop and maintain staff expertise necessary to carry out the services
described herein.
(2.) County staff shall maintain and assimilate program and technical information
provided by OHA, attend drinking water training events provided by OHA, and
maintain access to information sources as necessary to maintain and improve staff
expertise.
(3.) County shall hire or contract with personnel registered as Environmental Health
Specialists or Professional Engineers with experience in environmental health to
carry out the services described herein.
(4.) Documentation of Field Activities and Water System Contacts: County shall
prepare and maintain adequate documentation of field activities and water system
contacts as required to:
(a.) Maintain accurate and current public water system inventory information.
(b.) Support formal enforcement actions.
(c.) Describe current regulatory status of water systems.
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(d.) Evaluate the perfonnance and effectiveness of the drinking water program.
(e.) Guide and plan program activities.
(5.) Minimum Standard for Documentation: County shall, at a minimum, prepare and
maintain the following required documentation (see fonns provided in the
Attachments):
(a.) Water system surveys and significant deficiencies.
(b.) Water System lnfonnation (Inventory), Entry Structure Diagram, and Source
Infonnation updates.
(c.) Field and office contacts in response to complaints, water quality alerts,
PNCs, violations, enforcement actions, regulatory assistance, requests for
regulatory infonnation, and plan review follow-up.
(d.) Waterborne illness reports and investigations.
(e.) All correspondence with public water systems under County's jurisdiction
and OHA.
(f.) Documentation regarding reports and investigations of spills and other
emergencies affecting or potentially affecting water systems.
(g.) Copies of public notices received from water systems.
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(6.) Monthly Reporting: County shall submit to OHA on a monthly basis the
information in Section (5.) above in order for OHA to maintain state primacy for the
federal safe drinking water program.
(7.) OHA Audits: County shall give OHA free access to all County records and
documentation pertinent to this Agreement for the purpose ofOHA audits.
c. Performance Measures. OHA will use three (3) performance measures to evaluate
County's performance: (1) water system surveys completed, (2) alert responses, (3) and
resolution of priority non-complying systems (PNCs).
(1.) Water system surveys completed. Calculation: number of surveys completed
divided by the number of surveys required.
(2.) Alert responses. Calculation: number ofalerts responded to divided by the number
of alerts generated.
(3.) Resolution of PNCs. Calculation: number of PNCs resolved divided by the total
number of PNCs.
d. Responsibilities of OHA. This Agreement is intended to enable County to independently
conduct an effective local drinking water program. OHA recognizes its role to provide
assistance and program support to County to foster uniformity of statewide services.
OHA agrees to provide the following services to County:
(1.) OHA will distribute drinking water program and technical information on a monthly
basis to County.
(2.) OHA will sponsor at least one annual 8-hour workshop for County drinking water
program staff at a central location and date to be detennined by OHA. OHA will
provide workshop registration, on-site lodging, meals, and arrange for continuing
education unit (CEU) credits. County is responsible for travel expenses for County
staff to attend.
(3.) OHA will sponsor at least one regional 4-hour workshop at three (3) locations at
locations and dates to be determined by OHA to supplement the annual workshop.
OHA will provide training materials and meeting rooms. County is responsible for
travel expenses for its staff to attend.
(4.) OHA will provide County with the following information from the public water
system database:
(a.) Immediately: Alert data.
(b.) Continuously: Listings of PNCs.
(c.) Quarterly: Performance data.
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(d.) Continuously: Individual water system inventory and water quality data.
(5.) OHA will support electronic communications and data transfer between OHA and
County to reduce time delays, mailing costs, and generation of hard copy reports.
(6.) OHA will maintain sufficient technical staff capacity to assist County staff with
unusual drinking water problems that require either more staff than is available to
County for a short time period, such as a major emergency, or problems whose
technical nature or complexity exceed the capability of County staff. When on-site
assistance from OHA is requested, County is responsible for: scheduling OHA
assistance, making arrangements to involve the water system operator, being present
when OHA assistance is conducted in the field, and conducting follow-up work as
necessary after the on-site assistance.
(7.) OHA will refer to County all routine inquiries or requests for assistance received
from public water system operators for which County is responsible.
(8.) OHA will prepare formal enforcement actions against public water systems in the
subject County, except for licensed facilities, according to the priorities contained in
the current State/EPA agreement. OHA will prepare other actions against water
systems as requested by County and as agreed by OHA.
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EXHIBIT A
Part 3
Payment and <Financial Reporting
1. Required Program Services Using Base Funds: For the time period commencing October
1,2011 through June 30, 2013, OHA will make seven (7) equal quarterly payments in the
amount of$9,386.00 for a total not-to-exceed amount of $65,702.00 in Required Program
Services using Base Funds.
2. Required Program Services and Supplemental Program Services Using Invoiced
<Funds: OHA will pay, pursuant to an invoice that is submitted by County and that is
accepted and approved by OHA, for Invoiced Services provided by County and as set forth in
this Agreement. OHA payments to County for Invoiced Services under this Agreement shall
not exceed the amount of$98,557.00 for the time period October 1,2011 through June 30,
2013.
County invoices with itemization of work performed with non-EPA water systems must be
separated from the work performed with EPA water systems. All invoices for work
performed under this Agreement must be submitted to OHA no later than 60 days after the
end of this Agreement. Invoicing received after the 60 day period will not be paid, unless
prior arrangements have been made. Each invoice must include complete documentation of
the itemized actions taken.
a. Investigation of Water Quality Alerts: County may submit an invoice to OHA
for $210.00 for each investigation of a water quality alert for a regulated
contaminant. The invoice must include the alert identification number.
b. Resolution of Priority Noncompliers (PNCs): County may submit an invoice to
OHA for $1,050.00 for work completed under Exhibit A, Part 2.a.(2.)(b.), for each
PNC resolution when a water system's system score was 11 points or more. PNC is
resolved when the system score drops below 11 points after having received County
consultation. OHA will make a maximum of one payment per year per PNC water
system.
c. Enforcement Action Tracking and Follow-up: County may submit an invoice to
OHA for $1,400 forthe completion of all corrections listed in an OHA enforcement
action for a community and nontransient noncommunity water system. County may
submit an invoice to OHA for $560.00 for completion of enforcement at a transient
noncommunity or non-EPA water system. Invoice must include a summary of all
water system contacts, verifications of completions, failures to meet correction dates,
and contacts with OHA regarding the enforcement action.
d. Water System Surveys: County may submit an invoice to OHA for $1,120.00 for
each Water System Survey completed of a community and nontransient
noncommunity water system. County may submit an invoice to OHA for $560.00 for
each Water System Survey of a transient noncommunity water system.
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1
e. Emergency Response Plan Development Assistance:
(1.) County may submit an invoice to OHA for $140.00 for technical assistance
provided by telephone, email or US mail to a public water system for
developing an Emergency Response Plan. County may only submit one
invoice per public water system consulted. OHA will not pay more than
$140.00 per public water system consulted regardless of the number of
consultations.
(2.) County may submit an invoice to OHA for $350.00 for technical assistance
provided at the public water system site for developing an Emergency
Response Plan. County may only submit one invoice per public water system
consulted. OHA will not pay more than $350.00 per public water system site
visit regardless ofthe number of consultation site visits. If County is already
on site for a water system survey, OHA will not pay additionally for ERP
technical assistance.
(3.) County may submit an invoice to OHA for $350.00 for each completed
Emergency Response Plan received by County if, after County review, it is
determined that the Emergency Response Plan meets minimum requirements.
County may only submit one invoice per public water system consulted.
OHA will not pay more than $350.00 per completed Emergency Response
Plan received by County regardless of the number of Emergency Response
Plans received from a single, subject public water system.
f. Violations: County may submit an invoice to OHA for $210.00 for each monitoring
and reporting violation that is investigated and returned to compliance. The invoice
must include the violation identification number.
g. Inventory and Documentation of New Water Systems: County may submit an
invoice to OHA for $700.00 for the identification of a water system that is not in the
OHA inventory. This task applies only to existing systems that are not in the OHA
inventory and that have not had a water system survey performed to gather the
necessary inventory information. If a survey is used to collect the inventory
information, this task does not apply and is not payable.
h. Follow-Up on Deficiencies Noted on Water System Surveys: OHA will pay as
follows:
(1.) If deficiencies do not consist entirely of administrative, monitoring, or
management and operations deficiencies, OHA will pay upon approval ofeither a
correction ofall deficiencies OR the submission ofan approved corrective action
plan. County may submit an invoice to OHA after all significant deficiencies and
rule violations have been corrected; or, if all deficiencies and rule violations are
not corrected, County may submit an approved, written corrective action plan for
payment. As applicable, County's invoice must list all deficiencies and the dates
they were corrected. OHA will pay $560.00 for each community and
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nontransient, noncommunity water system and $280.00 for each transient
noncommunity water system.
(2.) If deficiencies consist entirely of administrative items, such as, but not limited
to: no coliform sampling plan, no operations and maintenance manual, or no
ordinance or enabling authority, upon correction of all administrative
deficiencies County may submit an invoice to OHA and OHA will pay
$280.00 for each community and nontransient, noncommunity water system
and $140.00 for each transient noncommunity system.
(3.) If deficiencies consist entirely of monitoring, or management and operations
deficiencies, such as, but not limited to: monitoring not current, MCL
violations, public notice violations, or major modifications not approved,
County may, if applicable, invoice these types of corrections using the
appropriate service listed under 2.(2.), Required Program Services Using
Invoiced Funds. OHA will not pay for corrections of monitoring, or
management and operations deficiencies if invoiced as deficiency corrections
when, if applicable, they can be invoiced in a different manner.
i. Engineering Plan Review Inspections: County may submit an invoice to OHA for
$420.00 for each plan review inspection completed.
j. Customized and Negotiated Work: County may submit an invoice to OHA for
payment ofcustomized and negotiated work. County must submit documentation of
progress on achieving each of the expected outcomes for each task listed on the OHA
approved proposal. OHA will make payment only when the outcomes are
documented as completed and approved by OHA.
3. COUNTY shall submit monthly invoices for services provided, along with supporting
documentation, in a format acceptable to OHA.
4. TRAVEL and OTHER EXPENSES. OHA shall not reimburse County for any travel or
additional expenses under this Agreement.
5. AGREEMENT ADMINISTRATOR
The OHA employee assigned to monitor Agreement compliance, authorize payment, and
act as OHA's Agreement Administrator on matters concerning this Agreement shall be:
Office of Environmental Public Health
Drinking water Program
Thomas Mitchell
800 NE Oregon St.
Portland, OR 97232
Phone: 971-673-0417
Fax: 971-673-0694
Email: thomas.j.mitchell@state.or.us
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EXHIBIT A
Part 4
Special Terms and Conditions
1. Confidentiality of Client Information
a. All information as to personal facts and circumstances obtained by the County on
the client shall be treated as privileged communications, shall be held
confidential, and shall not be divulged without the written consent of the client,
the responsible parent of a minor child, or his or her guardian except as required
by other terms of this Agreement. Nothing prohibits the disclosure of information
in summaries, statistical, or other form, which does not identify particular
individuals.
b. The use or disclosure of information concerning clients shall be limited to persons
directly connected with the administration of this Agreement. Confidentiality
policies shall be applied to all requests from outside sources.
c. OHA, County and any subcontractor will share information as necessary to
effectively serve OHA clients.
2. Amendments
a. OHA reserves the right to amend or extend the Agreement under the following
general circumstances:
(I) OHA may extend the Agreement for additional periods of time up to a
total Agreement period of six (6) years, and for additional money
associated with the extended period(s) of time. The determination for any
extension for time may be based on OHA's satisfaction with performance
of the work or services provided by the County under this Agreement.
(2) OHA may periodically amend any payment rates throughout the life of the
Agreement proportionate to increases in Portland Metropolitan Consumer
Price Index; and to provide Cost Of Living Adjustments (COLA) ifOHA
so chooses. Any negotiation of increases in rates to implement a COLA
will be as directed by the Oregon State Legislature.
b. OHA further reserves the right to amend the Statement of Work based on the
original scope of work for the following:
(1) Programmatic changes/additions or modifications deemed necessary to
accurately reflect the original scope of work that may not have been
expressed in the original Agreement or previous amendments to the
Agreement;
(2) Implement additional phases of the Work; or
(3) As necessitated by changes in Code of Federal Regulations, Oregon
Revised Statutes, or Oregon Administrative Rules which, in part or in
combination, govern the provision of services provided under this
Agreement.
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c. Upon identification, by any party to this Agreement, of any circumstance which
may require an amendment to this Agreement, the parties may enter into
negotiations regarding the proposed modifications. Any resulting amendment
must be in writing and be signed by all parties to the Agreement before the
modified or additional provisions are binding on either party. All amendments
must comply with Exhibit B, Section 22. "Amendments" of this Agreement.
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EXHIBIT B
Standard Terms and Conditions
1. Governing Law, Consent to Jurisdiction. This Agreement shall be governed by and
construed in accordance with the laws of the State of Oregon without regard to principles
of conflicts oflaw. Any claim, action, suit or proceeding (collectively, "Claim") between
the parties that arise from or relate to this Agreement shall be brought and conducted
solely and exclusively within a circuit court in the State of Oregon of proper jurisdiction.
THE PARTIES, BY EXECUTION OF THIS AGREEMENT, HEREBY CONSENT TO
THE IN PERSONAM JURISDICTION OF SAID COURTS. Except as provided in this
section, neither party waives any form of defense or immunity, whether sovereign
immunity, governmental immunity, immunity based on the eleventh amendment to the
Constitution of the United States or otherwise, from any Claim or from the jurisdiction of
any court. The parties acknowledge that this is a binding and enforceable agreement and,
to the extent permitted by law, expressly waive any defense alleging that either party does
not have the right to seek judicial enforcement of this Agreement.
2. Compliance with Law. Both parties shall comply with laws, regulations and executive
orders to which they are subject and which are applicable to the Agreement or to the
Work. Without limiting the generality of the foregoing, both parties expressly agree to
comply with the following laws, regulations and executive orders to the extent they are
applicable to the Agreement: (a) all applicable requirements of state civil rights and
rehabilitation statutes, rules and regulations; (b) all state laws requiring reporting of
Client abuse; (c) ORS 659A.400 to 659A.409, ORS 659A.145 and all regulations and
administrative rules established pursuant to those laws in the construction, remodeling,
maintenance and operation of any structures and facilities, and in the conduct of all
programs, services and training associated with the Work. These laws, regulations and
executive orders are incorporated by reference herein to the extent that they are applicable
to the Agreement and required by law to be so incorporated. All employers, including
County and OHA, that employ subject workers who provide services in the State of
Oregon shall comply with ORS 656.017 and provide the required Workers'
Compensation coverage, unless such employers are exempt under ORS 656.126.
3. Independent Contractors. The parties agree and acknowledge that their relationship is
that of independent contracting parties and that County is not an officer, employee, or
agent of the State of Oregon as those terms are used in ORS 30.265 or otherwise.
4. Representations and Warranties
a. County represents and warrants as follows:
(1) Organization and Authority. County is a political subdivision of the State
of Oregon duly organized and validly existing under the laws of the State
of Oregon. County has full power, authority and legal right to make this
Agreement and to incur and perform its obligations hereunder.
(2) Due Authorization. The making and performance by County of this
Agreement (a) have been duly authorized by all necessary action by
County and (b) do not and will not violate any provision of any applicable
law, rule, regulation, or order of any court, regulatory commission, board,
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or other administrative agency or any provision of County's charter or
other organizational document and (c) do not and will not result in the
breach of, or constitute a default or require any consent under any other
agreement or instrument to which County is a party or by which County
may be bound or affected. No authorization, consent, license, approval of,
filing or registration with or notification to any governmental body or
regulatory or supervisory authority is required for the execution, delivery
or perfonnance by County of this Agreement.
(3) Binding Obligation. This Agreement has been duly executed and delivered
by County and constitutes a legal, valid and binding obligation of County,
enforceable in accordance with its tenns subject to the laws of bankruptcy,
insolvency, or other similar laws affecting the enforcement of creditors'
rights generally.
(4) County has the skill and knowledge possessed by well-infonned members
of its industry, trade or profession and County will apply that skill and
knowledge with care and diligence to perfonn the Work in a professional
manner and in accordance with standards prevalent in County's industry,
trade or profession;
(5) County shall, at all times during the tenn of this Agreement, be qualified,
professionally competent, and duly licensed to perfonn the Work; and
(6) County prepared its proposal related to this Agreement, if any,
independently from all other proposers, and without collusion, fraud, or
other dishonesty.
b. OHA represents and warrants as follows:
(1) Organization and Authority. OHA has full power, authority and legal right
to make this Agreement and to incur and perfonn its obligations
hereunder.
(2) Due Authorization. The making and perfonnance by OHA of this
Agreement (a) have been duly authorized by all necessary action by OHA
and (b) do not and will not violate any provision of any applicable law,
rule, regulation, or order of any court, regulatory commission, board, or
other administrative agency and (c) do not and will not result in the breach
of, or constitute a default or require any consent under any other agreement
or instrument to which OHA is a party or by which OHA may be bound or
affected. No authorization, consent, license, approval of, filing or
registration with or notification to any governmental body or regulatory or
supervisory authority is required for the execution, delivery or
performance by OHA of this Agreement, other than approval by the
Department of Justice if required by law.
(3) Binding Obligation. This Agreement has been duly executed and delivered
by OHA and constitutes a legal, valid and binding obligation ofOHA,
enforceable in accordance with its terms subject to the laws of bankruptcy,
insolvency, or other similar laws affecting the enforcement of creditors'
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rights generaIly.
c. Warranties Cumulative. The warranties set forth in this section are in addition to,
and not in lieu of, any other warranties provided.
5. Funds Available and Authorized Clause.
a. The State of Oregon's payment obligations under this Agreement are conditioned
upon OHA receiving funding, appropriations, limitations, allotment, or other
expenditure authority sufficient to allow OHA, in the exercise of its reasonable
administrative discretion, to meet its payment obligations under this Agreement
County is not entitled to receive payment under this Agreement from any part of
Oregon state government other than OHA. Nothing in this Agreement is to be
construed as permitting any violation of Article XI, section 7 of the Oregon
Constitution or any other law regulating liabilities or monetary obligations of the
State of Oregon. OHA represents that as of the date it executes this Agreement, it
has sufficient appropriations and limitation for the current biennium to make
payments under this Agreement
b. Payment Method. Payments under this Agreement will be made by Electronic
Funds Transfer (EFT), unless otherwise mutually agreed, and shall be processed
in accordance with the provisions of OAR 407-120-0100 through 407-120-0380
or OAR 410-120-1260 through OAR 410-120-1460, as applicable, and any other
Oregon Administrative Rules that are program-specific to the billings and
payments. Upon request, County shall provide its taxpayer identification number
(TIN) and other necessary banking infonnation to receive EFT payment. County
shall maintain at its own expense a single financial institution or authorized
payment agent capable of receiving and processing EFT using the Automated
Clearing House (ACH) transfer method. The most current designation and EFT
information will be used for all payments under this Agreement County shall
provide this designation and information on a form provided by OHA. In the
event that EFT information changes or the County elects to designate a different
financial institution for the receipt of any payment made using EFT procedures,
the County shall provide the changed information or designation to OHA on a
OHA-approved form. OHA is not required to make any payment under this
Agreement until receipt of the correct EFT designation and payment information
from the County.
6. Recovery of Overpayments. Ifbillings under this Agreement, or under any other
Agreement between County and OHA, result in payments to County to which County is
not entitled, OHA, after giving to County written notification and an opportunity to
object, may withhold from payments due to County such amounts, over such periods of
time, as are necessary to recover the amount of the overpayment, subject to Section 7
below. Prior to withholding, if County objects to the withholding or the amount proposed
to be withheld, County shall notify OHA that it wishes to engage in dispute resolution in
accordance with Section 19 of this Agreement
7. Nothing in this Agreement shall require County or OHA to act in violation of state or
federal law or the Constitution of the State of Oregon.
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8. Ownership of Intellectual Property.
a. Except as otherwise expressly provided herein, or as otherwise required by state
or federal law, OHA will not own the right, title and interest in any intellectual
property created or delivered by County or a subcontractor in connection with the
Work. With respect to that portion of the intellectual property that the County
owns, County grants to OHA a perpetual, worldwide, non-exclusive, royalty-free
and irrevocable license, subject to any provisions in the Agreement that restrict or
prohibit dissemination or disclosure of information, to (1) use, reproduce, prepare
derivative works based upon, distribute copies of, perform and display the
intellectual property, (2) authorize third parties to exercise the rights set forth in
Section 8.a.(1) on OHA's behalf, and (3) sublicense to third parties the rights set
forth in Section 8.a.(1).
I
b. If state or federal law requires that OHA or County grant to the United States a
license to any intellectual property, or if state or federal law requires that OHA or
the United States own the intellectual property, then County shall execute such
further documents and instruments as OHA may reasonably request in order to
make any such grant or to assign ownership in the intellectual property to the
United States or OHA. To the extent that OHA becomes the owner of any
intellectual property created or delivered by County in connection with the Work,
OHA will grant a perpetual, worldwide, non-exclusive, royalty-free and
irrevocable license, subject to any provisions in the Agreement that restrict or
prohibit dissemination or disclosure of information, to County to use, copy,
distribute, display, build upon and improve the intellectual property.
c. County shall include in its subcontracts terms and conditions necessary to require
that subcontractors execute such further documents and instruments as OHA may
reasonably request in order to make any grant of license or assignment of
ownership that may be required by federal or state law.
9. County Default. County shall be in default under this Agreement upon the occurrence of
any of the following events:
a. County fails to perform, observe or discharge any of its covenants, agreements or
obligations set forth herein;
1 b. Any representation, warranty or statement made by County herein or in any
documents or reports relied upon by OHA to measure the delivery of Work, the
expenditure of payments or the performance by County is untrue in any material
respect when made;
c. County (1) applies for or consents to the appointment of, or taking of possession
by, a receiver, custodian, trustee, or liquidator of itself or all of its property, (2)
admits in writing its inability, or is generally unable, to pay its debts as they
become due, (3) makes a general assignment for the benefit of its creditors, (4) is
adjudicated a bankrupt or insolvent, (5) commences a voluntary case under the
Federal Bankruptcy Code (as now or hereafter in effect), (6) files a petition
seeking to take advantage of any other law relating to bankruptcy, insolvency,
reorganization, winding-up, or composition or adjustment of debts, (7) fails to
controvert in a timely and appropriate manner, or acquiesces in writing to, any
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petition filed against it in an involuntary case under the Bankruptcy Code, or (8)
takes any action for the purpose of effecting any of the foregoing; or
d. A proceeding or case is commenced, without the application or consent of
County, in any court of competent jurisdiction, seeking (1) the liquidation,
dissolution or winding-up, or the composition or readjustment of debts, of
County, (2) the appointment of a trustee, receiver, custodian, liquidator, or the like
of County or of all or any substantial part of its assets, or (3) similar relief in
respect to County under any law relating to bankruptcy, insolvency,
reorganization, winding-up, or composition or adjustment of debts, and such
proceeding or case continues undismissed, or an order, judgment, or decree
approving or ordering any of the foregoing is entered and continues unstayed and
in effect for a period of sixty consecutive days, or an order for relief against
County is entered in an involuntary case under the Federal Bankruptcy Code (as
now or hereafter in effect).
10. OHA Default. OHA shall be in default under this Agreement upon the occurrence of any
of the following events:
a. OHA fails to perform, observe or discharge any of its covenants, agreements, or
obligations set forth herein; or
b. Any representation, warranty or statement made by OHA herein or in any
documents or reports relied upon by County to measure performance by OHA is
untrue in any material respect when made.
11. Termination.
a. County Termination. County may terminate this Agreement:
(I) For its convenience, upon at least 30 days advance written notice to OHA;
(2) Upon 45 days advance written notice to OHA, if County does not obtain
funding, appropriations and other expenditure authorizations from
County's governing body, federal, state or other sources sufficient to
permit County to satisfY its performance obligations under this Agreement,
as determined by County in the reasonable exercise of its administrative
discretion;
(3) Upon 30 days advance written notice to OHA, if OHA is in default under
this Agreement and such default remains uncured at the end of said 30 day
period or such longer period, if any, as County may specify in the notice;
or
(4) Immediately upon written notice to OHA, if Oregon statutes or federal
laws, regulations or guidelines are modified, changed or interpreted by the
Oregon Legislative Assembly, the federal government or a court in such a
way that County no longer has the authority to meet its obligations under
this Agreement.
b. OHA Termination. OHA may terminate this Agreement:
(I) For its convenience, upon at least 30 days advance written notice to
County;
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i (2) Upon 45 days advance written notice to County, if OHA does not obtain
funding, appropriations and other expenditure authorizations from federal,
state or other sources sufficient to meet the payment obligations of OHA
I under this Agreement, as determined by OHA in the reasonable exercise of
its administrative discretion. Notwithstanding the preceding sentence,
OHA may terminate this Agreement, immediately upon written notice to
County or at such other time as it may determine if action by the Oregon
Legislative Assembly or Emergency Board reduces OHA's legislative
authorization for expenditure of funds to such a degree that OHA will no
longer have sufficient expenditure authority to meet its payment
obligations under this Agreement, as determined by OHA in the
reasonable exercise of its administrative discretion, and the effective date
for such reduction in expenditure authorization is less than 45 days from
the date the action is taken;
(3) Immediately upon written notice to County if Oregon statutes or federal
laws, regulations or guidelines are modified, changed or interpreted by the
Oregon Legislative Assembly, the federal government or a court in such a
way that OHA no longer has the authority to meet its obligations under
this Agreement or no longer has the authority to provide payment from the
funding source it had planned to use; ! i (4) Upon 30 days advance written notice to County, if County is in default
I
J under this Agreement and such default remains uncured at the end of said
30 day period or such longer period, if any, as OHA may specifY in the
notice;
(5) Immediately upon written notice to County, if any license or certificate
required by law or regulation to be held by County or a subcontractor to
perform the Work is for any reason denied, revoked, suspended, not
renewed or changed in such a way that County or a subcontractor no1 longer meets requirements to perform the Work. This termination right
may only be exercised with respect to the particular part of the Work
impacted by loss of necessary licensure or certification;
(6) Immediately upon written notice to County, if OHA determines that
County or any of its subcontractors have endangered or are endangering
the health or safety of a client or others in performing work covered by this
Agreement.
c. Mutual Termination. The Agreement may be terminated immediately upon
mutual written consent of the parties or at such time as the parties may agree in
the written consent.
12. Effect of Termination
a. Entire Agreement.
(I) Upon termination of this Agreement, OHA shall have no further obligation
to pay County under this Agreement.
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(2) Upon tennination of this Agreement, County shall have no further
obligation to perfonn Work under this Agreement.
b. Obligations and Liabilities. Notwithstanding Section I2.a., any tennination of this
Agreement shall not prejudice any obligations or liabilities of either party accrued
prior to such tennination.
13. Limitation of Liabilities. NEITHER PARTY SHALL BE LIABLE TO THE OTHER
FOR ANY INCIDENTAL OR CONSEQUENTIAL DAMAGES ARISING OUT OF OR
RELATED TO THIS AGREEMENT. NEITHER PARTY SHALL BE LIABLE FOR
ANY DAMAGES OF ANY SORT ARISING SOLELY FROM THE TERMINATION
OF THIS AGREEMENT OR ANY PART HEREOF IN ACCORDANCE WITH ITS
TERMS.
14. Insurance. County shall require subcontractors to maintain insurance as set forth in
Exhibit C, which is attached hereto.
15. Records Maintenance; Access. County shall maintain all financial records relating to this
Agreement in accordance with generally accepted accounting principles. In addition,
County shall maintain any other records, books, documents, papers, plans, records of
shipments and payments and writings of County, whether in paper, electronic or other fonn,
that are pertinent to this Agreement in such a manner as to clearly document County's
perfonnance. All financial records, other records, books, documents, papers, plans, records
of shipments and payments and writings of County whether in paper, electronic or other
fonn, that are pertinent to this Agreement, are collectively referred to as "Records." County
acknowledges and agrees that OHA and the Oregon Secretary of State's Office and the
federal government and their duly authorized representatives shall have access to all
Records to perfonn examinations and audits and make excerpts and transcripts. County
shall retain and keep accessible all Records for a minimum of six years, or such longer
period as may be required by applicable law, following final payment and tennination of
this Agreement, or until the conclusion of any audit, controversy or litigation arising out of
or related to this Agreement, whichever date is later. County shall maintain Records in
accordance with the records retention schedules set forth in OAR Chapter 166.
j 16. Information Privacy/Security/Access. If the Work perfonned under this Agreement
requires County or its subcontractor(s) to have access to or use of any OHA computer .1
1
system or other OHA Infonnation Asset for which OHA imposes security requirements,
and OHA grants County or its subcontractor(s) access to such OHA Infonnation Assets or
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l Network and Infonnation Systems, County shall comply and require all subcontractor(s)
to which such access has been granted to comply with OAR 943-014-0300 through OAR
943-014-0320, as such rules may be revised from time to time. For purposes of this
I section, "lnfonnation Asset" and "Network and lnfonnation System" have the meaning
set forth in OAR 943-014-0305, as such rule may be revised from time to time.
17. Force Majeure. Neither OHA nor County shall be held responsible for delay or defaultI caused by fire, civil unrest, labor unrest, natural causes, or war which is beyond the
reasonable control of OHA or County, respectively. Each party shall, however, make all
reasonable efforts to remove or eliminate such cause of delay or default and shall, upon
the cessation of the cause, diligently pursue perfonnance of its obligations under this
Agreement. OHA may tenninate this Agreement upon written notice to the other party
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after reasonably detennining that the delay or breach will likely prevent successful
perfonnance of this Agreement.
18. Assignment of Agreement, Successors in Interest.
a. County shall not assign or transfer its interest in this Agreement without prior
written approval of OHA. Any such assignment or transfer, if approved, is subject
to such conditions and provisions as OHA may deem necessary. No approval by
OHA of any assignment or transfer of interest shall be deemed to create any
obligation ofOHA in addition to those set forth in the Agreement.
b. The provisions of this Agreement shall be binding upon and shall inure to the
! benefit of the parties hereto, and their respective successors and pennitted assigns.
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19. Alternative Dispute Resolution. The parties should attempt in good faith to resolve any
dispute arising out of this agreement. This may be done at any management level,
including at a level higher than persons directly responsible for administration of the
agreement. In addition, the parties may agree to utilize a jointly selected mediator or
arbitrator (for non-binding arbitration) to resolve the dispute short of litigation.
i 20. Subcontracts. County shall not enter into any subcontracts for any of the Work required
by this Agreement without OHA's prior written consent. In addition to any other
provisions OHA may require, County shall include in any pennitted subcontract under
this Agreement provisions to require that OHA will receive the benefit of subcontractor
1 perfonnance as ifthe subcontractor were the County with respect to Sections 1,2, 3,4, 8,
I 15, 16, 18,21, and 23 of this Exhibit B. OI-IA's consent to any subcontract shall not
relieve County of any of its duties or obligations under this Agreement.
21. No Third Party Beneficiaries. OHA and County are the only parties to this Agreement
and are the only parties entitled to enforce its tenns. The parties agree that County's
perfonnance under this Agreement is solely for the benefit of OHA to assist and enable
OHA to accomplish its statutory mission. Nothing in this Agreement gives, is intended to
give, or shall be construed to give or provide any benefit or right, whether directly,
indirectly or otherwise, to third persons any greater than the rights and benefits enjoyed
by the general public unless such third persons are individually identified by name herein
and expressly described as intended beneficiaries of the tenns of this Agreement.
22. Amendment. No amendment, modification or change of tenns of this Agreement shall
bind either party unless in writing and signed by both parties and when required the
Department of Justice. Such amendment, modification or change, if made, shall be
effective only in the specific instance and for the specific purpose given.
23. Severability. The parties agree that if any tenn or provision of this Agreement is declared
by a court of competent jurisdiction to be illegal or in contlict with any law, the validity
ofthe remaining tenns and provisions shall not be affected, and the rights and obligations
of the parties shall be construed and enforced as if the Agreement did not contain the
particular tenn or provision held to be invalid.
24. Survival. Sections 1,4,5,6,7,8,12,13,14,15,16,19,21,22,23,24,25,26,28, 29, 30
and 31 of this Exhibit B shall survive Agreement expiration or tennination as well as those
the provisions of this Agreement that by their context are meant to survive. Agreement
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expiration or termination shall not extinguish or prejudice either party's right to enforce
this Agreement with respect to any default by the other party that has not been cured.
25. Notice. Except as otherwise expressly provided in this Agreement, any communications
between the parties hereto or notices to be given hereunder shall be given in writing by
personal delivery, facsimile, or mailing the same, postage prepaid to County or OHA at
the address or number set forth below, or to such other addresses or numbers as either
party may indicate pursuant to this section. Any communication or notice so addressed
and mailed shan be effective five days after mailing. Any communication or notice
delivered by facsimile shall be effective on the day the transmitting machine generates a
receipt of the successful transmission, if transmission was during normal business hours
of the recipient, or on the next business day, if transmission was outside normal business
hours of the recipient. To be effective against the other party, any notice transmitted by
facsimile must be confirmed by telephone notice to the other party at number listed
below. Any communication or notice given by personal delivery shall be effective when
actually delivered to the addressee.
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I
OHA: Office of Contracts & Procurement
250 Winter St NE, Room 306
I
f Salem, OR 97301-1080
Telephone: 503-945-5818
Facsimile Number: 503-378-4324
1
COUNTY: (see page one)
26. Headings. The headings and captions to sections of this Agreement have been inserted
for identification and reference purposes only and shall not be used to construe the
meaning or to interpret this Agreement.
27. Counterparts. This Agreement and any subsequent amendments may be executed in
several counterparts, all of which when taken together shall constitute one agreement
binding on all parties, notwithstanding that all parties are not signatories to the same
counterpart. Each copy ofthis Agreement and any amendments so executed shall
constitute an original.
28. Waiver. The failure of either party to enforce any provision of this Agreement shall not
constitute a waiver by that party of that or any other provision. No waiver or consent shall
be effective unless in writing and signed by the party against whom it is asserted.
29. Construction. Reserved
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1
30. Contribution. If any third party makes any claim or brings any action, suit or proceeding
alleging a tort as now or hereafter defined in ORS 30.260 ("Third Party Claim") against a
party (the "Notified Party") with respect to which the other party ("Other Party") may ~ have liability, the Notified Party must promptly notify the Other Party in writing of the
Third Party Claim and deliver to the Other Party a copy of the claim, process, and all
legal pleadings with respect to the Third Party Claim. Either party is entitled to participate
in the defense of a Third Party Claim, and to defend a Third Party Claim with counsel of
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l its own choosing. Receipt by the Other Party of the notice and copies required in this I
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i
paragraph and meaningful opportunity for the Other Party to participate in the
investigation, defense and settlement of the Third Party Claim with counsel of its own
choosing are conditions precedent to the Other Party's liability with respect to the Third
Party Claim.
With respect to a Third Party Claim for which the State is jointly liable with the County
(or would be ifjoined in the Third Party Claim ), the State shall contribute to the amount
of expenses (including attorneys' fees), judgments, fines and amounts paid in settlement
actually and reasonably incurred and paid or payable by the County in such proportion as
is appropriate to reflect the relative fault of the State on the one hand and of the County
on the other hand in connection with the events which resulted in such expenses,
judgments, fines or settlement amounts, as well as any other relevant equitable
considerations. The relative fault of the State on the one hand and of the County on the
other hand shall be determined by reference to, among other things, the parties' relative
intent, knowledge, access to information and opportunity to correct or prevent the
circumstances resulting in such expenses, judgments, fines or settlement amounts. The
State's contribution amount in any instance is capped to the same extent it would have
been capped under Oregon law if the State had sole liability in the proceeding.
With respect to a Third Party Claim for which the County is jointly liable with the State
(or would be ifjoined in the Third Party Claim), the County shall contribute to the
amount of expenses (including attorneys' fees), judgments, fines and amounts paid in
settlement actually and reasonably incurred and paid or payable by the State in such
proportion as is appropriate to reflect the relative fault of the County on the one hand and
of the State on the other hand in connection with the events which resulted in such
expenses, judgments, fines or settlement amounts, as well as any other relevant equitable
considerations. The relative fault of the County on the one hand and of the State on the
other hand shall be determined by reference to, among other things, the parties' relative
intent, knowledge, access to information and opportunity to correct or prevent the
circumstances resulting in such expenses, judgments, fines or settlement amounts. The
County's contribution amount in any instance is capped to the same extent it would have
been capped under Oregon law if it had sole liability in the proceeding.
31. Indemnification by Subcontractors. County shall take all reasonable steps to cause its
contractor(s) that are not units oflocal government as defined in ORS 190.003, if any, to
indemnifY, defend, save and hold harmless the State of Oregon and its officers,
employees and agents ("Indemnitee") from and against any and all claims, actions,
liabilities, damages, losses, or expenses (including attorneys' fees) arising from a tort (as
now or hereafter defined in ORS 30.260) caused, or alleged to be caused, in whole or in
part, by the negligent or willful acts or omissions of County's contractor or any of the
officers, agents, employees or subcontractors of the contractor( "Claims"). It is the
specific intention of the parties that the Indemnitee shall, in all instances, except for
Claims arising solely from the negligent or willful acts or omissions of the Indemnitee,
be indemnified by the contractor from and against any and all Claims.
32. Stop-Work Order. OHA may, at any time, by written notice to the County, require the
County to stop all, or any part of the work required by this Agreement for a period of up
to 90 days after the date of the notice, or for any further period to which the parties may
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agree through a duly executed amendment. Upon receipt of the notice, County shall
immediately comply with the Stop-Work Order terms and take all necessary steps to
minimize the incurrence of costs allocable to the work affected by the stop work order
notice. Within a period of 90 days after issuance of the written notice, or within any
extension of that period to which the parties have agreed, OHA shall either:
a. Cancel or modify the stop work order by a supplementary written notice; or
b. Terminate the work as permitted by either the Default or the Convenience
provisions of Section 11.Termination.
If the Stop Work Order is canceled, OHA may, after receiving and evaluating a request
by the County, make an adjustment in the time required to complete this Agreement and
the Agreement price by a duly executed amendment.
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EXHIBIT C
Subcontractor Insurance Requirements
County shall require its first tier contractor(s) that are not units of local government as defined in
ORS 190.003, if any, to: i) obtain insurance specified under TYPES AND AMOUNTS and
meeting the requirements under ADDITIONAL INSURED, "TAIL" COVERAGE, NOTICE OF
CANCELLATION OR CHANGE, and CERTIFICATES OF INSURANCE before the
contractors perform under contracts between County and the contractors (the "Subcontracts"),
and ii) maintain the insurance in full force throughout the duration of the Subcontracts. The
insurance must be provided by insurance companies or entities that are authorized to transact the
business of insurance and issue coverage in the State of Oregon and that are acceptable to OHA.
County shall not authorize contractors to begin work under the Subcontracts until the insurance is
in full force. Thereafter, County shall monitor continued compliance with the insurance
requirements on an annual or more frequent basis. County shall incorporate appropriate
provisions in the Subcontracts permitting it to enforce contractor compliance with the insurance
requirements and shall take all reasonable steps to enforce such compliance. Examples of
"reasonable steps" include issuing stop work orders (or the equivalent) until the insurance is in
full force or terminating the Subcontracts as permitted by the Subcontracts, or pursuing legal
action to enforce the insurance requirements. In no event shall County permit a contractor to
work under a Subcontract when the County is aware that the contractor is not in compliance with
the insurance requirements. As used in this section, a "first tier" contractor is a contractor with
whom the county directly enters into a contract. It does not include a subcontractor with whom
the contractor enters into a contract.
TYPES AND AMOUNTS.
1. WORKERS COMPENSATION. Insurance in compliance with ORS 656.017, which
requires all employers that employ subject workers, as defined in ORS 656.027, to provide
workers' compensation coverage for those workers, unless they meet the requirement for an
exemption under ORS 656.126(2). Employers Liability insurance with coverage limits ofnot
less than $500,000 must be included.
2. PROFESSIONAL LIABILITY
[2J Required by OHA [] Not required by OHA.
Professional Liability Insurance covering any damages caused by an error, omission or
negligent act related to the services to be provided under the Subcontract, with limits not
less than the following, as determined by OHA, or such lesser amount as OHA approves
in writing:
[2J Per occurrence for all claimants for claims arising out of a single accident or
occurrence:
I Subcontract not-to-exceed under this Required Insurance Amount:
Agreement:
I .$0 -$1,000,000. $1,000,000.
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$1,000,001. -$2,000,000. $2,000,000.
$2,000,001. -$3,000,000. $3,000,000.
In excess of $3,000,001. $4,000,000.
3. COMMERCIAL GENERAL LIABILITY
~Required by OHA Not required by OHA.
Commercial General Liability Insurance covering bodily injury, death, and property damage in
a form and with coverages that are satisfactory to OHA. This insurance shall include personal
injury liability, products and completed operations. Coverage shall be written on an occurrence
form basis, with not less than the following amounts as determined by OHA, or such lesser
amount as OHA approves in writing:
Bodily Injury, Death and Property Damage:
~ Per occurrence for all claimants for claims arising out of a single accident or
occurrence:
I Subcontract not-to-exceed under this
Agreement:
Required Insurance Amount:
$0 -$1,000,000. $1,000,000.
$1,000,001. -$2,000,000. $2,000,000.
$2,000,001. -$3,000,000. $3,000,000.
In excess of $3,000,001. $4,000,000.
4. AllTOMOBILE LIABILITY INSllRANCE
~Required by OHA Not required by OHA.
Automobile Liability Insurance covering all owned, non-owned and hired vehicles. This
coverage may be written in combination with the Commercial General Liability
Insurance (with separate limits for "Commercial General Liability" and "Automobile
Liability"). Automobile Liability Insurance must be in not less than the following
amounts as determined by OHA, or such lesser amount as OHA approves in writing:
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7
Bodily Injury, Death and Property Damage:
~ Per occurrence for all claimants for claims arising out of a single accident or
occurrence:
I Subcontract not-to-exceed ~nder this Required Insurance Amount:
• Agreement:
$0 -$1,000,000. $1,000,000.
$1,000,001. -$2,000,000. $2,000,000.
$2,000,001. -$3,000,000. $3,000,000.
In excess of $3,000,001. $4,000,000.
5. ADDITIONAL INSURED. The Commercial General Liability insurance and
Automobile Liability insurance must include the State of Oregon, its officers, employees
and agents as Additional Insureds but only with respect to the contractor's activities to be
performed under the Subcontract. Coverage must be primary and non-contributory with
any other insurance and self-insurance.
6. "TAIL't COVERAGE. If any of the required insurance policies is on a "claims made"
basis, such as professional liability insurance, the contractor shall maintain either "tail"
coverage or continuous "claims made" liability coverage, provided the effective date of
the continuous "claims made" coverage is on or before the effective date of the
Subcontract, for a minimum of 24 months following the later of: (i) the contractor's
completion and County's acceptance of all Services required under the Subcontract or, (ii)
the expiration of all warranty periods provided under the .subcontract. Notwithstanding the
foregoing 24-month requirement, if the contractor elects to maintain "tail" coverage and if
the maximum time period "tail" coverage reasonably available in the marketplace is less
than the 24-month period described above, then the contractor may request and OHA may
grant approval of the maximum "tail" coverage period reasonably available in the
marketplace. If OHA approval is granted, the contractor shall maintain "tail" coverage for
the maximum time period that "tail" coverage is reasonably available in the marketplace.
NOTICE OF CANCELLATION OR CHANGE. The contractor or its insurer must
provide 30 days' written notice to County before cancellation of, material change to,
potential exhaustion of aggregate limits of, or non-renewal of the required insurance
coverage(s).
8. CERTIFICATE(S) OF INSURANCE. County shall obtain from the contractor a
certificate(s) of insurance for all required insurance before the contractor performs under
the Subcontract. The certificate(s) or an attached endorsement must specify: i) all entities
and individuals who are endorsed on the policy as Additional Insured and ii) for insurance
on a "claims made" basis, the extended reporting period applicable to "tail" or continuous
"claims made" coverage.
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EXHIBIT D
Required Federal Terms and Conditions
Unless exempt under 45CFR Part 87 for Faith-Based Organizations (Federal Register, July 16,
2004, Volume 69, #136), or other federal provisions, County shall comply and, as indicated,
require all subcontractors to comply with the following federal requirements to the extent that
they are applicable to this Agreement, to County, or to the Work, or to any combination of the
foregoing. For purposes of this Agreement, all references to federal and state laws are references
to federal and state laws as they may be amended from time to time.
1. Miscellaneous Federal Provisions
County shall comply and require all subcontractors to comply with all federal laws,
regulations, and executive orders applicable to the Agreement or to the delivery of Work.
Without limiting the generality of the foregoing, County expressly agrees to comply and
require all subcontractors to comply with the following laws, regulations and executive
orders to the extent they are applicable to the Agreement: (a) Title VI and VII of the Civil
Rights Act of 1964, as amended, (b) Sections 503 and 504 of the Rehabilitation Act of
1973, as amended, (c) the Americans with Disabilities Act of 1990, as amended, (d)
Executive Order 11246, as amended, (e) the Health Insurance Portability and
Accountability Act of 1996, as amended, (f) the Age Discrimination in Employment Act
of 1967, as amended, and the Age Discrimination Act of 1975, as amended, (g) the
Vietnam Era Veterans' Readjustment Assistance Act of 1974, as amended, (h) all
regulations and administrative rules established pursuant to the foregoing laws, (i) all
other applicable requirements of federal civil rights and rehabilitation statutes, rules and
regulations, and (j) all federal law governing operation of Community Mental Health
Programs, including without limitation, all federal laws requiring reporting of client
abuse. These laws, regulations and executive orders are incorporated by reference herein
to the extent that they are applicable to the Agreement and required by law to be so
incorporated. No federal funds may be used to provide Work in violation of 42 U.S.C.
14402.
2. Equal Employment Opportunity
If this Agreement, including amendments, is for more than $10,000, then County shall
comply and require all subcontractors to comply with Executive Order 11246, entitled
"Equal Employment Opportunity," as amended by Executive Order 11375, and as
supplemented in Department of Labor regulations (41 CFR Part 60).
3. Clean Air, Clean Water, EPA Regulations
If this Agreement, including amendments, exceeds $100,000 then County shall comply
and require all subcontractors to comply with all applicable standards, orders, or
requirements issued under Section 306 of the Clean Air Act (42 U.S.C. 7606), the Federal
Water Pollution Control Act as amended (commonly known as the Clean Water Act) (33
U.S.c. 1251 to 1387), specifically including, but not limited to Section 508 (33 U.S.c.
1368), Executive Order 11738, and Environmental Protection Agency regulations (2 CFR
Part 1532), which prohibit the use under non-exempt Federal contracts, grants or loans of
facilities included on the EPA List of Violating Facilities. Violations shall be reported to
OHA, United States Department of Health and Human Services and the appropriate
OHA Agreement #13693 1-0, vkd Page 37 of65
OHA IGA County Template reviewed August 25,20 II
Regional Office of the Environmental Protection Agency. County shall include and
require all subcontractors to include in all contracts with subcontractors receiving more
than $100,000, language requiring the subcontractor to comply with the federal laws
identified in this section.
4. Energy Efficiency
County shall comply and require all subcontractors to comply with applicable mandatory
standards and policies relating to energy efficiency that are contained in the Oregon
energy conservation plan issued in compliance with the Energy Policy and Conservation
Act U.S.c. 6201 et.seq. (Pub. L. 94-163).
5. Truth in Lobbying
The County certifies, to the best of the County's knowledge and belief that:
a. No federal appropriated funds have been paid or will be paid, by or on behalf of
County, to any person for influencing or attempting to influence an officer or
employee of an agency, a Member of Congress, an officer or employee of
Congress, or an employee of a Member of Congress in connection with the
awarding of any federal contract, the making of any federal grant, the making of
any federal loan, the entering into of any cooperative agreement, and the
extension, continuation, renewal, amendment or modification of any federal
contract, grant, loan or cooperative agreement.
b. If any funds other than federal appropriated funds have been paid or will be paid
to any person for influencing or attempting to influence an officer or employee of
any agency, a Member of Congress, an officer or employee of Congress, or an
employee of a Member of Congress in connection with this federal contract, grant,
loan or cooperative agreement, the County shall complete and submit Standard
Form LLL, "Disclosure Form to Report Lobbying" in accordance with its
instructions.
c. The County shall require that the language of this certification be included in the
award documents for all subawards at all tiers (including subcontracts, subgrants,
and contracts under grants, loans, and cooperative agreements) and that all
subrecipients and subcontractors shall certify and disclose accordingly.
This certification is a material representation of fact upon which reliance was placed
when this Agreement was made or entered into. Submission of this certification is a
prerequisite for making or entering into this Agreement imposed by section 1352, Title 31
of the U.S. Code. Any person who fails to file the required certification shall be subject to
a civil penalty of not less than $10,000 and not more than $100,000 for each such failure.
6. HIPAA Compliance
OHA is a Covered Entity with respect to its healthcare components as described in OAR
943-014-0015 for purposes of the Health Insurance Portability and Accountability Act
and the federal regulations implementing the Act (collectively referred to as HIP AA), and
OAR 125-055-0100 through OAR 125-055-0130. OHA must comply with HIPAA to the
extent that any Work or obligations of OHA arising under this Agreement are covered by
HIP AA. County shall determine if County will have access to, or create any protected
health information in the performance of any Work or other obligations under this
OHA Agreement # 136931-0, vkd Page 38 of65
OHA lOA County Template reviewed August 25, 2011
Agreement. To the extent that County will have access to, or create any protected health
information to perform functions, activities, or services for, or on behalf of, a healthcare
component of OHA in the performance of any Work required by this Agreement, County
shall comply and cause all subcontractors to comply with OAR 125-055-0100 through
OAR 125-055-0130 and the following:
a. Privacy and Security of Individually Identifiable Health Information. Individually
Identifiable Health Information about specific individuals is confidential.
Individually Identifiable Health Information relating to specific individuals may
be exchanged between County and OHA for purposes directly related to the
provision of services to Clients which are funded in whole or in part under this
Agreement. To the extent that County is performing functions, activities, or
services for, or on behalf of, a healthcare component of OHA in the performance
of any Work required by this Agreement, County shall not use or disclose any
Individually Identifiable Health Information about specific individuals in a
manner that would violate OHA Privacy Rules, OAR 943-014-0000 et. seq., or
OHA Notice of Privacy Practices. A copy of the most recent OHA Notice of
Privacy Practices is posted on the OHA web site at:
https:/!apps.state.or.us!cfl/FORMS/ enter form number 2090 or may be obtained
from OHA.
b. Data Transactions Systems. If County intends to exchange electronic data
transactions with a health care component of OHA in connection with claims or
encounter data, eligibility or enrollment information, authorizations or other
electronic transaction, County shall execute an EDI Trading Partner Agreement
with OHA and shall comply with OHA EDI Rules.
c. Consultation and Testing. If County reasonably believes that the County's or
OHA's data transactions system or other application ofHIPAA privacy or security
compliance policy may result in a violation of HIPAA requirements, County shall
promptly consult the OHA Information Security Office. County or OHA may
initiate a request for testing of HIP AA transaction requirements, subject to
available resources and the OHA testing schedule.
7. Resource Conservation and Recovery
I
County shall comply and require all subcontractors to comply with all mandatory
standards and policies that relate to resource conservation and recovery pursuant to the
Resource Conservation and Recovery Act (codified at 42 U.S.c. 6901 et. seq.). Section
6002 of that Act (codified at 42 U.S.C. 6962) requires that preference be given in
procurement programs to the purchase of specific products containing recycled materials
identified in guidelines developed by the Environmental Protection Agency. Current
guidelines are set forth in 40 CFR Part 247.
i 8. Audits
I
a. County shall comply and, if applicable, require a subcontractor to comply, with
the applicable audit requirements and responsibilities set forth in the Office of
Management and Budget Circular A-133 entitled "Audits of States, Local
Governments and Non-Profit Organizations."
I
I OHA Agreement # 136931-0, vkd Page 39 of65
OHA IGA County Template reviewed August 25, 2011
I
I
b. Sub-recipients shall also comply with applicable Code of Federal Regulations
(CFR) sections and OMB Circulars governing expenditure of federal funds. State,
local and Indian Tribal Governments and governmental hospitals must follow
OMB A-I 02. Non-profits, hospitals, colleges and universities must follow 2 CFR
Part 215. Sub-recipients shall monitor any organization to which funds are passed
for compliance with CFR and OMB requirements.
9. Debarment and Suspension
County shall not permit any person or entity to be a subcontractor if the person or entity is
listed on the non-procurement portion of the General Service Administration's "List of
Parties Excluded from Federal Procurement or Nonprocurement Programs" in accordance
with Executive Orders No. 12549 and No. 12689, "Debarment and Suspension". (See 2
CFR Part 180.) This list contains the names of parties debarred, suspended, or otherwise
excluded by agencies, and contractors declared ineligible under statutory authority other
than Executive Order No. 12549. Subcontractors with awards that exceed the simplified
acquisition threshold shall provide the required certification regarding their exclusion
status and that of their principals prior to award.
10. Drug-Free Workplace
County shall comply and require all subcontractors to comply with the following
provisions to maintain a drug-free workplace: (i) County certifies that it will provide a
drug-free workplace by publishing a statement notifying its employees that the unlawful
manufacture, distribution, dispensation, possession or use of a controlled substance,
except as may be present in lawfully prescribed or over-the-counter medications, is
prohibited in County's workplace or while providing services to OHA clients. County's
notice shall specify the actions that will be taken by County against its employees for
violation of such prohibitions; (ii) Establish a drug-free awareness program to inform its
employees about: The dangers of drug abuse in the workplace, County's policy of
maintaining a drug-free workplace, any available drug counseling, rehabilitation, and
employee assistance programs, and the penalties that may be imposed upon employees for
drug abuse violations; (iii) Provide each employee to be engaged in the performance of
services under this Agreement a copy of the statement mentioned in paragraph (i) above;
I
(iv) Notify each employee in the statement required by paragraph (i) above that, as a
condition of employment to provide services under this Agreement, the employee will:
abide by the terms of the statement, and notify the employer of any criminal drug statute
conviction for a violation occurring in the workplace no later than five (5) days after such
conviction; (v) Notify OHA within ten (10) days after receiving notice under
i subparagraph (iv) above from an employee or otherwise receiving actual notice of such
conviction; (vi) Impose a sanction on, or require the satisfactory participation in a drug
abuse assistance or rehabilitation program by any employee who is so convicted as
required by Section 5154 of the Drug-Free Workplace Act of 1988; (vii) Make a good
faith effort to continue a drug-free workplace through implementation of subparagraphs
(i) through (vi) above; (viii) Require any subcontractor to comply with subparagraphs (i)
through (vii) above; (ix) Neither County, or any of County's employees, officers, agents
or subcontractors may provide any service required under this Agreement while under the
influence of drugs. For purposes of this provision, "under the influence" means: observed
abnormal behavior or impairments in mental or physical perfonnance leading a
OHA Agreement # 136931-0, vkd Page 40 of65
OHA lOA County Template reviewed August 25, 20 II
reasonable person to believe the County or County's employee, officer, agent or
subcontractor has used a controlled substance, prescription or non-prescription
medication that impairs the County or County's employee, officer, agent or
subcontractor's performance of essential job function or creates a direct threat to OHA
clients or others. Examples of abnormal behavior include, but are not limited to:
hallucinations, paranoia or violent outbursts. Examples of impairments in physical or
mental performance include, but are not limited to: slurred speech, difficulty walking or
performing job activities; and (x) Violation of any provision of this subsection may result
in termination of this Agreement.
11. Pro-Children Act
County shall comply and require all subcontractors to comply with the Pro-Children Act
of 1994 (codified at 20 U.S.C. section 6081 et. seq.).
12. Medicaid Services
County shall comply with all applicable federal and state laws and regulation pertaining
to the provision of Medicaid Services under the Medicaid Act, Title XIX, 42 U.S.c.
Section 1396 et. seq., including without limitation:
a. Keep such records as are necessary to fully disclose the extent of the services
provided to individuals receiving Medicaid assistance and shall furnish such
information to any state or federal agency responsible for administering the
Medicaid program regarding any payments claimed by such person or institution
for providing Medicaid Services as the state or federal agency may from time to
time request. 42 U .S.c. Section 1396a(a)(27); 42 CFR 43 1.1 07(b)(1) & (2).
b. Comply with all disclosure requirements of 42 CFR 1002.3(a) and 42 CFR 455
Subpart (8).
c. Maintain written notices and procedures respecting advance directives in
compliance with 42 U.S.C. Section 1396(a)(57) and (w), 42 CFR 43 1. 107 (b)(4),
and 42 CFR 489 subpart I.
d. Certify when submitting any claim for the provision of Medicaid Services that the
information submitted is true, accurate and complete. County shall acknowledge
County's understanding that payment of the claim will be from federal and state
funds and that any falsification or concealment of a material fact may be
prosecuted under federal and state laws.
I
e. Entities receiving $5 million or more annually (under this Agreement and any
other Medicaid Agreement) for furnishing Medicaid health care items or services
shall, as a condition of receiving such payments, adopt written fraud, waste and
abuse policies and procedures and inform employees, contractors and agents about
the policies and procedures in compliance with Section 6032 of the Deficit
Reduction Act of2005, 42 U.S.C. § 1396a(a)(68).
13. Agency-based Voter Registration
If applicable, County shall comply with the Agency-based Voter Registration sections of
I the National Voter Registration Act of 1993 that require voter registration opportunities
be offered where an individual may apply for or receive an application for public
assistance.
f
I OHA Agreement #136931-0, vkd Page 41 of65I OHA lOA County Template reviewed August 25,2011
-----
ATfACHMENT 1
Page 1 of 13
-----~.----------------------------------------------------.
XYZ Water System PWS ID: 41 #fJ:II##
Water System Survey
DHS Drinking Water Program
Survey Date: mm/dd1yy
Page 1 of22
Deficiency Summary
SuNeyor: _________________________________
County: _______Date Corrective Action Plan is due:
Spring/other source:
o 0 Treatment:
Surface water treatment:
Other treatment:
0 0 Finished Water Storage:
0 0 Distribution:
0 Monitoring:
0 Management & Operations:
0 0 Operator Certification:
0 0 Other Rule Violations:
,",OITII .."'"..,..
Rev.l()'()7-09
Rev. 10-07-09
OHA Agreement # 136931-0, vkd Page 42 of65
OHA IGA County Template reviewed August 25, 2011
A TIACHMENT 1
Page 2 of 13
XYZ Water System PWS ID: 41 #####
Water System Survey Survey Date: mm/dd/yy
DHS Drinking Water Program
Page 4 of 22
Inventory and Narrative
o Outstanding Performer County:
o Non Transient
Non-Community (NTNC)
o Transient
Non-Community (TNC)
o State ReglNon EPA (NP)
Primary Administrative Contact (Mailing Address):
Contact Name:
Title: ___________________
Cell: -'--_~'_____________
Stroot
CityfStatelZip: ___~_______~_____
Legal/Owner Address:
Contact Name: Phone:
Title: ___________________Cell: ..,(__-'-___________
Street Address: Emergency #: -'-_~'--________
City/StatelZip Email: ____ ~__________
System Physical Address:
Contact Name:
Title: ___________________
Street Address: Emergency #: -'-_~'--________
CitylStatelZip. Email:
Emergency Systems Available:
Name: PWSIO#:
Narrative:
-----------_..._--------------------~
Cell: --'-_--''--___________
Rev. 10-07-09
Rev. 10-07-09
I
I I
i
I
~
j
I
ATTACHMENT 1
Page 3 of 13
XYZ Water System
Water System Survey
DHS Drinking Water Program
PWS !O: 41
Survey Date:
#iJI#I#
mm/ddtyy
Page 6 of 22
Water System Schematic
Rllv. 1G-07-09
Rev. 10-07-09
AITACIDvIENT 1
Page 4 of 13
XYZ Water System
Water System Survey
DHS Drinking Water Program
PWS ID: 41
Survey Date:
#####
mm/dd/yy
Page 70122
Source Information
10
A
(location where water enters
distribution and is sampled)
Name
" Gl
s:: 0 -::3 ~ c: 'jijGl
"C II> is E :::J c: c:c: 0 C) 1/1 III 0 :::J ~ ::l E 1:10 :; ...: ...: ... .... :::J ::3 ::3 Ql II>C> 1.1) C> Q. Q. Q. 1.1)
00000 [J C
00000 [ ] 0
0 0 0 0 0 0 0
0 0 o [ [ ] [] []
Begins Ends
CI> .... >"'Cu c <.> II><lS
't: <I> 'jij C C
C C <l> 0::I '" 0 I:' "'CCI) E VI c ..: Ql <lS... <lS E:I <I> CI> .c
Q. D.. rn Ul «
~
C
II>
21
Q) ~ E 0 wz
DC
DO
DO
DC
"0
.J!I
<)
Ql
C
C
0 <IIu CVI
is 0 z
AA 0 0 [ [J [J 0 JI[ 0 DO o fl noD ODD 0 DO o [] C [] CI 0 []I[ DOC]
[J [] [ [] [J [J ] 0 0 00
ODD 0 0 0 10 0010 ,.,
ODDOOOODODO o [J C [J [J 0 [] ClOD CI
Treatment
Codes'"
Treatment
Codes....
'Land Use Codes: (A) Pristine Forest (8) Imgllted Crops (e) Non-Irrigated Crops (D) Pasture (E) Ught Industry (F) Heavy Industry (G) UrbDn-Sewered
Area (H) Rural On-Site Sewage Disposal (I) Urban On-Site Sewage Disposal (J) Rangeland (K) Managed Forest (Ll Commercial (M) RKreatlonal Use
"See "Trealmenl' page for treatment code descriptions.
list current operational patterns for all sources (e.g., Well 1 used continuously @ 100 gpm. Be as specific as possible)
Yes No
DODoes the water system have water rights for all sources? D Not Required
7o 0 For GW systems, have there been any modifications to the existing well(s) -or-s-p"""'ri-ng--=('""'s):-C(:-e-g-.de-e-p-en-e-do--,--=ch:--a-n-ge-'-in-
screened interval, springbox reconstruction, etc.)? Describe below:
o 0 Has a Source Water Assessment been completed by 0 DWP or 0 DEQ? If yes, attach delineation map and review
boundaries with operator.
o 0 Has system implemented source water protection strategies? If yes, describe below:
o 0 Is the water system interested in source water protection? If yes, contact regional geologist at 541-726-2581.
Icomments:
Rev. 10-07-09
Rev. 10-07-09
AITACHMENT I
Page 8 of 13
XVZ Water System PWS 10: 41 #####
Water System Survey Survey Date: mm/ddfyy
DHS Drinking Water Program
Page 17 0122
Treatment
'See 'Treatment Plant Inspection" page for details on filtration. "See "Disinfection" page for details on disinfection equipment .~See
Treatment Codes on back.
Yes No
D 0 Is equipment maintained properly?
D 0 Is redundant equipment available?
What lab eQuipment is available and used? fiar lestina, turbidimeter pH meter. etcJ:
D [J • Are chemicals NSF Standard 60 certified or equiy~lenl? (ONJA -no chemicals are used)
Comments:
Yes INo
DODoes system practice corrosion control? n n •Is corrosion control ooerated within oarameters sat bv DWP? ONIA
Comments:
Records Kept:
Yes/No Yes/No
DO o 0 Flowrate
DO
o 0 Treated pH o 0 Treated temperature
D 0 Raw turbidi article counts Treated turbidi!
Comments:
00
Rev.l()'O]"()9
Rev. 10-07-09
A TIACHMENT 1
Page 9 ofl3
XYl Water System PWS 10: 41 #####
Water System Survey Survey Date: mmJddlyy
DHS Drinking Water Program
Page 19 0122
Storage and Pressure Tanks
~~~~~~~~= ~~~~~~~~~~r7.~~~
• (G) Ground IE) Elevated (P) Pr.ssure
~~~-I
.WalartighL ...................................... ..
Curbed Hd (shoe box s )...........................
Drain to daylight ........................................
Overflow ...................................................
• Overflow/drain protected (screenIHaplvalve)... .
• Screened vanL...............................
Water level gauge .................................... ..
Bypass piping............................... .
Fence/gate ............................................. .
....... DNIA
Interior in good condition ........................... ..
Approved interior coating ..
Inspoction schedule .................................. ..
Cleaning schedule .....................................
Continuously disinfected • post '81 redwood)
m· i;.· Separate inlet/oulleL .................................H :~;~;;.:.;;u: •..•••.•.••.••..••••••••
if;;",;:::: Used for contact time .................................... __ ,
Accessible for maintenance ..............................
Separate inlet/oullet..................................
Bypass piping. ... ...... .. ...... .............
Access port .................................·......0 NfA
Drain ........................................................... .
Pressure relief device ...................................
Air bladder/diaphragm .....................................
Valve for adding aiL ................... .
Water level 5i hi
0
0
0
0
0
0
o o
0
0
0
.-__...,Total Volume: ~==;-;:==::::
0
0
0
0
0
0
0
0
0
0
;NQ .yes:··'No·
0 0
o o
o o
0
Rev. HI·01-09
Rev. 10-07-09
ATTACHMENT 1
Page 10 of 13
XYZ Water System PWS 10: 41 #####
Water System SUlVey SUlVay Dala: mm/dd/yy
OHS Drinking Water Program
Page 2Q of 22
Distribution System Information
Service Area and Facility Map
Yes. No o Does the system have a service area and facility map (indicate features on map): o Booster pumps 0 Sources-wells & withdrawal points o Pressure regulating valves 0 Storage fadlities (res9IVoirs)
Pressure zones 0 Treatmentfacilities
Sampling points Water lines (induding size and material)
Distribution Data
Yes No comments
• System pressure'" 20 psi
Are selVice connections metered? (what %)
Water system leakage <10%
Waterline depth >30"
Piping looped
Hydrants or blowoffs on all dead ends
Routine flushing (How often)
Adequate valving
Routine valve tuming (How often)
Asbestos cement (AC) pipe absent from system
o o o o o o
Comments:
Cross Connection Control (CWS, NTNC, and TNC)
Yes No N/A Comments
000 • Ordinance or enabling authority (CWS)
List of installed devices (eWS, NTNC, TNC) ~_________________o 0 o 0 • Devices tested annually (CWS, NTNC, TNC) __________________
DOD • Annual Summary Report submitted (CWS) o 0 • Certified Cross Connection
Control Specialist (CWS ". 300 connectionsl
rcomments:
Bd6ster Pumps .. .-\':.".<'-.. :.
Number Name (Iocatlonl
I
I
i
I
Comments:
. .:t':~;:;;:"':'i;.i':: .:,~;:,:.~:.-c.;·,:,~~:, :~"~r;""
Deficiencies or Comments
..... . .
~power
HP No
D ~=
Rev. 10-07-09
Rev. 10-07-09
ATTACHMENTl
Page II of 13
XVZ Water System PWS 10: 41 #####
Water System Survey SUivey Date: mm/ddlyy
DHS Drinking Water Program
Pagellof22
Water Quality Monitoring
Arsenic......................................................... 0
Inorganic Chemicals (Including Nibite) ........... (sw) 0
Inorganic Chemicals (Including Nitrtte) ........... (gw) 0
SOCs .. _.......... , .......................... , ...... , ............
VOCs (sw) ................................................. , ..
VOCs(gw} ....... ,.. .............. ,
Radionuclides (Community Water Systems Only):
GrossAlpha .................... ".,..... 0
Radium 226/228 .... " ................. , 0
Turbidity ..... , ............... " , ....... ',., , ... " ............... .
Source Water Coliform ................." ............. .
o 0 • Is all required monitoring current? IComments:
Yes No o 0 Has the system experienced chemical (last 5 years) or bacteriological (last 2 years) detections?
If yes, list what contaminant and when?
o •Have all MCL violations been addressed? N/A
DODoes the system have any monitoring reductions granted? Explain:
o • Does the system have a written coliform sampling plan?
Does the plan indude: Yes No Yes No
Rotation schedule o 0 Brief narrative 0
Repeat locationso 0 Distribution map 0 o 0 'Sample site locations 0 o o Source(s) 0 N/A
Are TIHM and HAA5 samples taken allocation of maximum residence time? Not required)
Where in the system are the monitoring sites for TIHM and HAAS?
Rev. 10-07-09
Rev. 10-07-09
AITACHMENT 1
Page 12 of 13
XYZ Water System PWS 10: 41 ##11##
Water System Survey Survey Data: mm/ddlyy
DHS Drinking Water Program
Page 22 of 22
Management & Operations
O&M Manual and Emergency Response Plan
Yes No o •Does system have an operation and maintenance manual? o O .•Does system have an emergency response plan?
Operator Certification
'ORC: direct responsible charge. Attach additional sheets if necessary \0 list all certified personnel.
Yes No o 0 Is ORC identified? o 0 • Is ORC certified at appropriate level? o 0 • Does system have written operimng protocols for other operators? 0 N/A
If DRC is a Contract Operator:
Yes No
DODoes OWP have contract on file? 0 N/A
How does contract operator work with system? 0 N/A
Plan Review/Master Plan
Yes No o 0 • Have all major modifications (since 8121181) been approved by DWP? o 0 Does system have a currenl plan review exemption for water main extensions? o 0 • Does the system have a current «20 yr. old) master plan? (0 No1 required if <: 300 connections)
What year was the plan completed? c=J o Does the master plan include a water conservation plan?
Compliance Status
Yes No o • Is water system in compliance (all orders resolved and not a significant non-complier}?
How many violations has the system had in the past two years? c=:J o o • Does the system issue Public Notice for Violations as required? 0 No violations requiring public notice
o 0 .Has a capacity assessment been completed by DWP? If yes, list deficiencies noted:
o 0 • Are consumer confidence reports sent 10 users each year and certified?
Rev. 10-07·09
Rev. 10-07-09
ATTACHMENTl
Page 13 of 13
XYZ Water System PWS ID: 41 #fI###
Water System Survey Survey Date: mmldd/yy
DHS Drinking Water Program
Page 30122
Transient (TNC) and State Regulated (Non-EPA) Water Systems
N/A N/A o Surface Source o Treatment
Yes No Yes No
o 0 Cartridge filter used (if not, use "WTp· form) o D.NSF 60161 certified (or equivalent)
o 0 • Turbidity requirements met o 0 Equipment maintained properly o 0 .Is system under SWTR order? o 0 Dosage recorded 0 N/A
N/A N/A o Well Construction &Protection* o Pressure Tanks·
Yes No Yes No
o 0 • Sanitary seal and casing watertight DOUsed for contact time o 0 .If vented. properly screened 0 not vented o 0 Accessible for maintenance o 0 .Raw waler sample tap o 0 Separate inlet/outlet o 0 • Treated sample tap 0 N/A (not treated) o 0 Bypass piping o 0 Protective housing D. 0 Drain o 0 Pitless adapter o 0 Pressure relief device o 0 Wellhead terminates::. 12-in. above slabfgrade o 0 Air bladder/diaphragm
o 0 • Wellhead protected from "-r=~----' o 0 Valve for adding air o 0 • Meets hazard setback o 0 Access port (if >1,000 gal)
o 0 Concrete slab around Cl'lsing o 0 Water level sight glass (if >1,000 gal) o 0 Well logs from each source *Attach 'Slorage & Pressure Tank" page for o 0 Pump to waste piping reservOirs
• Attach well information page if more than 1 well
N1A Monitoring
o Spring/Other Source Construction Yes No
Yes No o 0 • All Mel violations addressed 0 N/A o 0 • Impervious/durable material o 0 • Previous 12 months of routine
coliform sampling up to dateo 0 • Screened overflow o 0 Boltom drain and shutoff valve o 0 • Nitrate sampling up to date
[] 0 • Watertight access hatch/entry o 0 • Initial arsenic test done
o 0 Intercepting ditch o 0 • Coliform sampling plan
o 0 • Trealed water sample tap D NlA (not trealed) o 0 All violations from the past 2 years
resolved 0 N/A -no violations o 0 • Raw water sample lap o 0 • Meets hazard setback ft: 1-1_____-'
N/A Management o Chlorination and UV (Attach "Disinfection" page) Yes No
Yes No o 0 PWS constructed before 8121/81
o 0 Chlorination for: 0 Residual maintenance o 0 • Plan review approval 0 NfA o Disinfection (4.0-log virus) o 0 • Emergency Response Plan o Other:___________ o 0 • Operations and main!. manual
o 0 UV for: o Total coliform positive source D 0 • SNC or out of compliance with AO
o 4.0--1OQ virus (166 mJ/cnl) o 0 • Public notice notissUed as required
o 0 • Distribution: Required backftow o Other: devices tested annually 0 NfA
!comments:
Rev. 10-07-09
____________________________________________________ ___
A TIACHMENT 2
)tgl:le~rtment Water System Information
01 Human Services DHS Drinking Water Program
System: _____________________________________________
Contact with: _____________________________________
Phone: I ________J _________________
Staff member: ____________________________
r:J State [j County r:J Dept. of Agriculture [j Other
41DDDDD
PWSID
(j New system -Fill out Inventory
and Source Change forms.
r:J Built before 8/21/81
County: _________
Date: _____________
D Change system name: New Name______________________
D Change system statistics:
SeasonType * Size, Etc.
r:J All year r:J Seasonal(j Community (C) Population: 1
[j Non-transient
~====~ Begins: 1 ! / I I Ends: I ! / I I Connections: 1...1______.....non-community (P) mmFdd mm'dd
D Transient non-community (N) Service Chars*: 0 0 . Coliform Sampling
D State regulated (S) Period: D Monthly r:J QuarterlyownerShiP*:D
*see reverse fOf details County: .... Samples Required: L!____.....J1---------.
Certification License Responsible Agency
WT-WD-__ (j FE? D Not lic. r:J DHS D Ag. D State D County r:J Dept. of Ag.
D Contact change: D Also Owner D Also Operator D Also Direct Responsible Charge (DRC)
Name&Trrle----------------------------------------~---_
MailingAddress -----------______________________________________
City __________ State_____ Zip _____ Phone (,________________
D Alternate contact changes: [j Owner D Operator D Direct Responsible Charge (DRC)
Name & Title-__________________________________
MailingAddress ----------------------------------___
City ____________ State___ Zip _____ Phone { ____. ______________
D Activate/ Deactivate: Date o~f~a~ct~iv~a:tio~n:!./~d:ea:c~ti:va:t:io~n~(~re~q~u:ire~d~):::::=================:;
[j Activate System D OOB/Temp. Closed (N) r:J Merged (M) PWS id; r:J No longer Qualifies (5)
ti § (not seasonal closure) 41 ______ (Pop Drop. Split, etc.) ~ ~D Deactivate System Cl·~ D Duplicate (D) r:J Abandoned (A) r:J Never Qualified (U)
(has another 10) (Incorrectly Given 10)
[] Nm~:
Signature:___________~_____ ...0" ....._____________
White State Pink County DHS 8304 1/05
OHA Agreement # \3693\-0, vkd Page 55 of65
OHA IGA County Template reviewed August 25, 2011
A ITACHMENT 3
OHD Drinking Water Program
System: 41 00000
PWSID
Contact with: () County:
----------------------------~--~--------------------
Staff Member. Date:
o State o County o Dept. of Agriculture 0 Other
Entry Points
Source Type Available Treatment Codes Designated
Sam pie Point
b.@' ~ b<!' ~ :;., I"
,J' ~# if' <i>~ n ~.. rI'PX:e~~~s~: ~
~.I~D~-N~a~m~l~e----------._~if~O/--~~.-~~.~~~Be~Q;;n$~E~n=d.~~~~~~______________~~ .
A 0 0,0 0' 0 01 : , : [0 0 0 ~~--------------_r--~--~----~~~--~--------------+_OOOOOO!:\:iOiO 0 ~~--------------+-------~--~~,-~+---------------~------------I
OOOOOO!:!:!O 0 '0---------1
10 0 0 0 0 oi, ' ' I '0 D 0~~------------r--~~~~~~-·~~·~~'---------~-----------IOOOOOO!, ,: [DID 0I ~~---------__--+------~--~~'-L+_+_--------------L--------------I
o 0 0 0 0 oj : i : iO 0 10________---l
Diagram Entry Points Sources
(Show piping structure from sources thru entry points to distribution. (Ids for sources on on EP start with
Mork sources and entry pointS with id. names.) the EP ,d: Be for 3nd source on EP B)
'.
..." 1---'
.
i
ID Name----------1
AA
i
Notes __________________________________________________________
Date: ______ ~g~ -----------------------------------------
Page 56 of65OHA Agreement #136931-0, vkd
OHA IGA County Template reviewed August 25,2011
Source Info
AITACHMENT4 OHD [)rinking Water Program 41DDDDD
fWSiD
System: D DD
Entry 10 Source IDSource Nome:
Contact with:
Stoff Member: Dote:
~D State ' -=OC;;-unty
D New Source D Pre '81 0 ApPIan Revled'ew D NRe~ds Plan D Modify Source 0 Abandon/Disconnect Source
prov evlew
D
New Source Info
Availability 0 Pcnnanent 0 Seasonal 0 Emergency
Entry p.,int 0 System has single source
Structure 0 Source on EP by itself
o Other (please fill out EP diagram)
Latitude: 00
deg. mill. sec..
longitude: 00
sec:.
Copacity: Yr Installed: 1'--__--" gal. L.___....l
Basin Nome: _____________
Land Use
o Pristine Forest (Al
o Irrigated Crops (S)
o Non-Irrig. Crops (C)
o Posture (D)
o Ugh! Industry (E)
o He",,>, Industry (F)
DUrban Sewered Area (G)
o Rural On-Site Sew. Oisp. (H)
o Urban On-Site Sew. Disp. ill
o Rangeland (J)
o Managed Forest (I<)
o Commercial (Ll
o ReaeatiO<l Use (M)
Purchased Water Or Intertie Info
Waters: 0 Surface 0 Ground 0 Both
D Groundwater Info
Source Type 0 Well 0 Spring
Water Resource
WeIlID: DDDDDD
Depth to 1st Wtr r------,
Bearing Zn: ft.
Addtnl WBZs: 0 Yes 0 No 0 Unk.
Static Water Lvi: ~==~ft
Source Elevation: r,
Casing Seal: 0 Yes 0 No 0 Unk.
Seal Depth: '--__--" It
Screen Type: 0 Screened 0 Perforated 0 None
WHPA delineated: 0 Yes 0 No
o CfR 0 Num. Method o Amll)'tiooljHM 0 Other
Aquifer Info
Aquifer Nome: ____________
o alluvium o confined o vol conic
o sediinentary
o leaky confined
o unconfined o fractured o unknown o unknown
Geological Barrier: 0 Yes 0 No 0 Unknown
Deptn: '---__---' it. Thickness: IL-_____I ~.
Hydraulic Connection: 0 Yes 0 No 0 Unknown
o stream 0 lagoon 0 loke/pond 0 wetland 0 unknown
OtherjNotes ________________________
Sign: ----------------------------------------------Date: _____
OHA Agreement # 136931-0, vkd Page 57 of65
OHA IGA County Template reviewed August 25, 201 1
ATTACHMENT 5
Contact Report/Assistance Actions
OHA Drinking Water Program
Water System Name: _____________ PWS ID: ______
Reg. Agency: _____ County: ________ System Type:
Contact: Phone:
Who Responded:
Date: ------
Staff: 0 State 0 County D Dept. of Agriculture
Contact location: 0 By Phone D In Office D In Field
Summary:
Assistance Action Type: *Reason:
D Alerts -Water QU'ality (21)** o Coliform (TCR)
D Formal Enforcement (2V)* D Nitrate (N03)
o Emergency Resp/ OERS (2E) D Surface Water Treatment (SWTR) o Boil Water (2B)* D Disinfection Byproducts (DBPs)
D Complaint Investigation (2C) D lead & Copper (lCR)
D Disease Investigation (20) D Arsenic (AS)
D Capacity Development (2P) o IOC
D OW Protection (2W) Dvoc
D Plan Review (2G) Dsoc
D Monitoring & Reporting (2R)** D Rads
D Regulatory Assistance (2H) o Operations
D Training -Non-aHA (2A) o Other:
D Treatment Plant Site Visit (10)*
D ERP Completed (lJ) **list Alert or Violation IDs Here:
D Cross Connection (2X)
D Informallnspection(2M)
o Water System Survey Follow Up (if)o Other (20):
* Mark Assistance Reason
** list AlertNiolation IDs
Details:
Action Needed:
Rev. 06/2011
00
::t::t > > OERS incident # ->C'lao PERSON REPORTING INCIDENT;>""(1)
('")!:: o ::l Name:
t= (1)
::l ::l
q; Companyl Agency ....,
(1) V-l
3 0\ Phone No.
"0'0_V-l
to -Datenrc
@ "<
< ;><:" WHERE/WHEN INCIDENT OCCURRED ~. 0
~
(1)
0-Location:
;>
c::
~
;!l.
t-..)
U'l
N County:o
Date: Time:
Any Risk to Public Waters or Shellfish Growing
Areas?
Possible Water System(s) Involved?
Shellfish growing areas involved
'\l to ao
(1)
U'l
'0
S,
0\
U'l
EMERGENCY RESPONSE FORM
MATERIAL(S) DESCRIPTION & QUANTITY
HOW INCIDENT OCCURRED
Administrator? Date Time
Who?
DEQ? Date Time
Who?
CoHD? Date Time
Who?
Poison Control Center? Date Time
Who?
Office of Public Health? Date Time
Who?
OARS?
Who?
,P-ON SCENE CONTACT PERSON ~
Name: ('")
-Company/Agency ~ Z ....,
Phone No. 0\ -Date
Inhalation
Skin contact
Ingestion
Comments
Action Taken:
Report Taken by:
Report Referred to:
-
ATIACHMENT7 CHECKLIST FOR WATER SYSTEM PLAN REVIEW
Page 1 of5 Wells
N ~Jne of System: Date Plan Received:
Name of Project: Date Plan Reviewed:
PWSIt: ___________Project Reviewlt:
Engineer
*IF NEW SYSTEM -ROUTE THROUGH gIRlS HUGHES{KURT PUTNAM
BEFORE CONSTRUCTION (before well is drilled): Plan Review Field Visit
General: Y N Y N
Appropriate plan review fee received .................................................................................... 0 0
Land use compatibility statement or equivalent ...................................................................... 0 0
Water Right Permit required YIN Submitted ..................................................................... 0 0
Site Plan:
Is land use around well controlled by water supplier .............................................................. 0 0 ........0 0
Is sewage disposal prohibited within 100' of the wei!... ........................................................... 0 0 ........0 0
Is there a roadway within 100' of well site ............................................................................. 0 0 ........0 0
Is site prone to flooding ........................................................................................................ 0 0 ........0 0
Surface water source within 500' of well route to Kari if yes (name) ..................................... 0 0 ........00
Recommendations regarding pump test sent. ......................................................................... 0 0
Construction specifications (casing\seal placement-DN or
Well construction approved .................................................................................................. 0 0
AFTER CONSTRUCTION:
Well Log: .
Is well drillers log provided .................................................................................................. 0 0 ........0 0
Is thickness of casing at least 0.25" ....................................................................... ; ............... 0 0 ........ 0 0
Is there an annular cement grout seal around the casing .......................................................... 0 O ........0 0
Does the seal meet construction recommendations ................................................................. 00
Is the yield of the well suffcient to meet daily demand ............................................................ 0 0
Was well test pumped, if so when
The duration of the pump test _______-'-_.Hours Depth of well? ________
Pumping rate was GPM Confined aquifer? ________
Drawdown was _________.•~.~. Specific w.-J_______GPMJft drawdown
Intakes (screens/perf.,etc.) ___________________.________
Wellhead Plans:
Is reinforced concrete slab provided around welL................................................................. 0 0 ........0 O·
Docs casing extend 12" above the slab .................................................................................. 00........00
Is a water tight sanitary seal provided .................................................................................... 0 0 ........0 0
Provision made for disinfection ............................................................................................ 0 o ........00
Are provisions made for measuring to water leveL ................................................................ 0 0 ........0 0
Is a sample tap provided ....................................................................................................... 0 0 ........0 0
Can the output of well be pumped to waste ........................................................................... 0 0 ........0 0
Is there a flow meter provided on the pump discharge ............................................................. 0 0 ........0 0
Is the concrete slab properly drained ............. : ....................................................................... 0 0 ........0 0
Is the pump house lighted, healed, lockable, etc ..................................................................... 0 0 ........0 0
Is well house constructed to aJlow pump removal .................................................................. 0 0 ........0 0
Is a casing vent with a screened return bend provided ............................................................. 0 0 ........00
CHEMICAl, ANALYSIS RECEIVED: Inventory Updated?.......o 0 ........0 0
Bacteriological Yes_~_ No___ N/A.__ Inorganic Yes___ No___ N/A __
voe Yes___ No N/A___ Radiological Yes___ No___ N/A__
SOC Yes___ No___ N/A ___
Review Date:______________
Field Visit By: __________________ Date: ______________
OHA Agreement # 136931-0, vkd Page 60 of65
OHA lOA County Template reviewed August 20 II
AITACHMENT 7 CHECKLIST FOR WATER SYSTEM PLAN REVIEW
Page 2 of5 Springs
Name of System: Date Plan Received:
Name of Project: Date Plan Reviewed:
Project Review#: *PWS#:
Engineer County:
*IF NEW SYSTEM -ROUTE THROUGH CHRIS HUGHEStKURT PUTNAM
Plan Review Field Visit
BEFORE CONSTRUCTION: Y N Y N
Appropriate plan review fee recei ved ................................................................... , ................ 0 0
Land use compatibility statement or equivalent.. .................................................................... 0 0
Has area been surveyed for sources of comatmination ................................... : ........................ 0 0 ........0 0
If Yes, identify sources ______________________~.~_______
Does owner have a 100ft. radius of control around site .......................................................... 0 0 ........ 0 0
If no, is there a perpetual restrictive easement ........................................................................ 0 0 ........0 0
If no, is this site in a public road r.o.w ................................................................................... 0 0 ........00
Is there a public road within 100 ft of site .............................................................................. 0 D ........00
If yes, will site be protected from surface runofL ................................................................... 0 D ........ 00
Is the flow constant year around ........................................................................................... 0 0
Describe typical soil strata: _________________________~___
Type of
CONSTRUCTION SPECIFICATIONS:
Springoox Details:
Is construction material concrete ........................................................................................... 0 D ........ 00
If no, identify impervious material:
Is box watertighL ................................................................................................................. 0 0 ........0 0
ls there an access manhold ................................................................................................... 00........00
If so, is there an overlapping hatch cover ........................................................................... 00........00
If so, is there curbing ........................................................................................................... 0 0 ........0 0
Is there a bottom drain to waste ............................................................................................. 0 D ........ 00
ls there an overflow with a flap valve or screen ...................................................................... 0 D ........00
Is area graded such that runoff drains away ........................................................................... 0 0 ........0 0
Inflow Piping:
Was perforated pipe installed ............................................................................................... 0 0
Are perforations located on underside of pipe ........................................................................ 0 0
Was packed gravel bed installed around perforated pipe ......................................................... 0 0
If so, was it disinfected after installation ................................................................................ 0 0
Is there an impervious layer above intake .............................................................................. 0 0
Outlet Piping:
Is outlet pipe located above the floor bottom ...................... " .......... , ...................................... 0 0
IT so, how far? Is it screened ..... " ....................................................................... 0 0
Is there a valve near the springbox ........................................................................................ 0 0 ........0 0
Is there a sample tap ............................................................................................................ 0 0 ........0 0
Is piping sized correctly ........................................................................................................ 0 0
Identify size and type of pipe ................................................................................................ 0 0 ........0 0
Is adequate cover (30 in) provided for the pipe ....................................................................... 0 0 ........0 0
GENERAL AREA OF SPRING:
Is there an interceptor ditch uphilL ....................................................................................... 00........00
Is the area fenced with a locked gate ..................................................................................... DO ........00
Bacti and Chern Analysis Rec'd? ......•. 0 0 Inventory Updated? ............... 00........00
Review
Field Visit By: Date: .~__________
OHA Agreement # 136931-0, vkd Page 61 of65
OHA IGA County Template reviewed August 25,2011
I
CHECKLIST FOR WATER SYSTEM PLAN REVIEWATTACHMENT 7
Storage Facilities Page 3 of5
Name of System: Date Plan Received: -----~--~---
Name of Project: Date Plan Reviewed:
Project Review# PWS#
Engineer: County:
CONSTRUCTION: ~ Plan Review FieJd Visit
SITE PLAN: YN YN
Geologic evaluation .. ~.......................................................................................................0 0
Foundation adequate (undisturbed soil, bedrock. etc.) .......................................................... 00
Provisions for a fence or other vandal deterrence ............................................................... 00....... 00
CONSTRUCTION SPECIFICATIONS:
What is the capacity gallons
What material is the storage facility made ~.______~_______________~_
If it is redwood, are continuous chlorination provisions made .............................................. 0 0 ....... 0 0
If it is redwood, is there a reinforced concrete base ............................................................. 0 0... .... 0 0
If it is concrete, is sufficient reinforcement supplied ...................................~ .......................0 0 ....... 0 0
If it is partially below ground, are footings drains provided ................................................. 0 D ....... 00
Is there a screened vent. ..................................................................................................... 0 D ....... 00
Is there a drain to daylight ................................................................................................. 0 D. . . . ... 0 0
Is there a flap valve at the end of the overflow .................................................................... 0 o ....... DO
Are overflow and drain common pipe ................................................................................. 0 D ....... DO
Is there a separate inlet/outlet pipe .................................................................................... .0 0 ....... 00
If a single inlet/outlet pipe, is there sufficient mixing ........................................................... DO
Is the facility baffled for contact time enhancement ............................................................ 0 0
If so to what degree _~_____~~.
1) Effective Volume
2) Estimated contact time _____
3) Contact time from traces study
Was a tracer study.performed ............................................................................................ 0 0 ....... DO
Is there a water level indicator ............................................................................................ 00....... 00
Is there an access manhole ................................................................................................ 0 0 ....... 0 0
Is there curbing and lockable watertight lid ........................................................................ 0 0....... 0 0
Is there a silt at the outlet piping ........................................................................................ 0 0
Does the interior coating meet with NSF requirements .................................................0 0
PRESSURE TANKs:
Is it installed above normal ground surface ......................................................................... 0 D ....... 00
Is bypass piping provided .................................................................................................. 0 D ....... 00
If it is greater than 1000 gallons, is there a manhole ............................................................ 0 0 ....... DO
Is there a drain, pressure gauge, and air blow-off valve ........................................................ 0 0....... 0 0
Is there means for adding air ............................................................................................. DO....... DO
Are there switches to control pumps .................................................................................. DO....... 00
Is the tank constructed of steel ........................................................................................... 00....... 00
Conditions/Comments:
Reviewed
Field Visit By: ____
Date: _______.......,-_
Date: _________
OHA Agreement # 136931-0, vkd
OHA IGA County Template reviewed August 25,2011
Page 62 of65
ATIACHMENT7 CHECKLIST FOR WATER SYSTEM PLAN REVIEW'
Page 4 ofS Continuous Disinfection
Name of System: Date Plan Received:
Name of Project: Date Plan Reviewed:
Project Review# PWS#
Engineer County:
Plan Field
CONSTRUCTION: Review Visit
General: Y N Y N
Appropriate plan review fee received ................................................................................................... 0 0
Type of Disinfectant. (Chlorine gas, hypochlorite, ozone, mixed oxidants) ............................................. 00.... 00
Type of feed system (Electric pump, meter drive, erosion gas) ............................................................... 0 0.... 0 0
Site Plan: ......
Is unit to be placed upstream from storage ............................................................................................ 0 0 .... 0 0
Construction Specifications:
Sample tap prior to disinfection ...................................................................................... " ................... 0 0 .... 0 0
Sample tap after disinfection ............................................................................................................... 0 0 .... 0 0
Low level alarm .................................................................................................................................. 00.... 00
Proportional to flow ........................................................................................................................... 0 0 .... 0 0
Chlorine Analyzer ............................................................................................................................ 00.... 00
Is a DPD test kit to be used to check residual ........................................................................................ 0 0 .... 0 0
Is there adequate contact time under all flow conditions ........................................................................ 0 0 .... 0 0
Are all equipment and chemicals NSF approved or equivalent ............................................................... 0 0 .... 0 0
Contact Time Calculation:
Maximum system flow: gallons/minute Verified ..................D 0
Amount of storage: gallons Verified ..................00
Contact Time available:
______~_ minutes
GAS CHLORINATORS
Is storage area enclosed ....................................................................................................................... 0 0 .... 0 0
Is storage area separated from other operating areas .............................................................................. 0 0 .... 0 0
Are provisions made for chaining cylinders .......................................................................................... 0 0 .... 0 0
Is room containing cylinders above ground ........................................................................................... 0 0 .... 0 0
Does the room have doors which open outward .................................................................................... 0 0 .... 0 0
Is the room ventilated with air intake above exhaust ............................................................................. 0 0 .... 0 0
If released, will gas flow into ventilation system ................................................................................... 0 0 .... 0 0
Are ventilation and lighting switches located outside ............................................................................. 00.... 00
Are ventilation and lighting switches corrosion resistant.. ...................................................................... 0 0 .... 0 0
Provisions made to measure weight of cylinder ..................................................................................... 0 0.... 0 0
SOURCE OF SUPPLy .................................................................................... Groundwater ............. 0 0 .... 0 0
Surface Water ............ 0 0.... 0 0
Water Quality Problem ........................................................................................................................ 00.... 00
Inventory Updated (required for payment) .........o 0 00
Conditions I
Calculations:
Reviewed Date:
Date:_____Field Visit
I
l
I
OHA Agreement # 136931-0, vkd Page 63 of65
OHA IGA County Template reviewed August 25, 2011
ATIACHMENT7 CHECKLIST FOR WATER SYSTEM PLAN REVIEW
Page 5 oiS Treatment -UV or Corrosion Control
Name of System: Date Plan Received:
Name of Project: Date Plan Reviewed:
Project Review#: PWS#: ___~________
Engineer
ULTRAVIOLET LIGHT: Plan Review Field Vi it
YN YN
Appropriate plan review fee received .................................................................................... 0 0
Installation:
Does the Unit meet the specs of NSF Standard 55 Class A ..................................................... 0 0 ........0 0
Make and Model _______________~________
Failsafe set point at 38mJ/cm2 (Dosage) ............................................................................... 0 0 ........ 00
........... Intensity of Unit mW/cm2
Unit Design Flow Rate
UV Lamps insulated from direct contact with water. .............................................................. 0 0 ........0 0
UV Lamps are remQvable ..................................................................................................... 00........00
Fixed flow rate control (set at gpm) .............................................................. 0 D ........0 0
UV sensor with alarm to measure lamp intensity ..................................................................0 0 ........ 00
Automatic water flow shut-off if intensity drops below 38mJ/cm2 .. ......................................00........0 0
Visual verification of operation oflanlps ............................................................................... 0 D ........00
Equipment able to withstand working pressure of at least lOO-psig ......................................... 0 0
Accessible for cleaning and replacement of lamp sleeves and sensor ....................................... 0 D ........0 0
Lamps changed per manufacturer's recommendation, or at least annually .............................0 0 ........ 0 0
Shutoff valves at inlet and outlet ........................................................................................... 0 0 ........00
NO Bypass around UV system (yes = no bypass) .................................................................. 0 0 ....... .0 0
Cornmen~: ~____~____~___ ~___ +______________ ~______________________________________
CQRROSION CONTROL:
Appropriate treatment based on WQP's and Guidance Manual ............................................... 00
Type (circle): Soda Ash, Caustic Soda, Aeration, Calcite Contactor, Ume, Orthophosphate, Sodium Bi-Carbonat
If Aeration, is chlorination practiced downstream .................................................................. 0 D ........ 0 0
Schematic drawing showing where chemicals are injected... ........... ........... ........... ........... ..... 0 0
Are chemicals injected separately ......................................................................................... 0 0 ........ 0 0
NSF Certified Additives and EquipmenL.............................................................................. 0 0 ........ 00
Feed pump acceptable .......................................................................................................... 0 0
Testing equipment available for testing WQP's...................................................................... 00........00
. Operation and maintenance manual or plan ........................................................................... 0 0 ........00
Letter sent with instructions 011 sampling and setting minimum WQP...................................... DO
I
Comments:
I
I
!
Inventory Updated? •.. , •. 0 0 ........0 0
Review Date:
Field Visit By: __~__ Date:
OHA Agreement # 136931-0, vkd Page 64 of65
OHA lOA County Template reviewed August 25, 2011
A ITACHMENT 8
Chemical Monitoring Schedule Change Form
DHS Drinking Water Program
System: PWSID #41
i I I III
Contact with: County:(-)
Staff Member: Date:
o State 0 County 0 Dept. of Ag 0 Other System Type (check one):
o Community (C) o Non·Transient Non Community (NTNC) o Transient Non-Community (NC) o State Regulated (NP)
Check if NeoSystem or
Sample Pt: For new systems, include all necessary chemicals and sampling points.
Chemical Groups Frequency Duration
Sample Point EP: EOd DateID N03, N02. IOe, VOC, a <'l ~ <J:> '" (Entry ID or SOC, AS, ALPH, f ::> ~ ~ S ~ ~ (Leave
II> e >~ ~ ~I!? ~~-.:: Blank ifDistribution URAN, RADI, etc. 0 1:: ..; til B~ w .. will Begin Date c: ., ., 8> IU., MonitoringSampling see reverse for 0 ::> E > 8> 8>0 ., c: c c: is to bePoint 10) complete Jist & ~ ...
descriptions J (J) 0 0 0 Continuous} I
Entry 10 (In SDWIS Entry 10 "A" will appear as Facility 10 "EP-A~ Entry 10 "B" will appear as "EP·B", etc.)
0 0 0 0 0 0 0 0 ! I I I
0 0 0 0 0 0 0 I 0 I I I I
0 0 0 0 0 0 0 0 I I I I
0 0 0 0 0 0 0 0 I I I I
0 0 0 0 0 0 0 0 I I I I
0 0 0 0 0 0 0 0 / I , ,
0 0 0 0 0 0 0 0 I I I I
0 0 0 0 0 0 0 0 , , I ,
i 0 0 0 0 0 0 0 0 I , I I
Distribution Sampling Point ID (In SOWIS Distrib. Sampling Point UA" will be identified as: Facility ID "DIST-A i
DBP Sam Ie Points must indicate either DBPMAX or OBP## e•• DBP01 at 5050 SE Stark 81. DBP02 at 800 NE 0p ( g on St etc.)}
Sample Site ID or Slreet OBP, ]?,
DIST-Aor Address ~ -a -i:' 2l~f!! 8~f! 8'" <IILCR, E ::>DBPMAX01, (Enter for oaps only -this ., c; '" C::Q)~ C:<l>'" c; ~;U Begin Date End Date or .. (J) c: ~ OJ;~ OJj~DBP01.etc. address will be used to tie ASBD " ..; OJ;>
sample results to the site} 0
0 i 0 0 I 0 0 0 I I I I I
I 0 0 0 0 0 0 I I I ,
0 0 0 0 0 0 I I I !
0 0 0 0 0 0 I I I I
Filtered and Raw Water TOC and Alkalinity Schedules for Water Treatment Plants ("WTP.A" for example)
2.5 log Conventional Plants Only
(TOGA schedules should be set for the Common Header and 2920 schedules should be set for the Water Treatment PlanD
TOCA,2920 Monthly=> 0 Quarterly => 0 I I J J
TOCA,2920 Monthly=> 0 Quarterly => 0 I , I ,
-
Comments:
Signature: ________________________Date:
For technical support and information, please call the Data Management Coordinator
(ph. 971-673-0405, M·F, 8aro-5pm PT) or visit hnp;!lwww.oregon.govIDHSlphldwp/tools.shtml Rev 01120/11
OHA Agreement # 136931-0, vkd Page 65 of65
OHA IGA County Template reviewed August 25, 2011
I