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GRANT FACE SHEET <br /> Grant Number: N19726 1 <br /> Washington State Department of Health (DOH) <br /> 1. Grantee 2. Grantee Doing Business As (optional) <br /> City of Everett Not Applicable <br /> 3200 Cedar St. <br /> Everett, Washington 98201 <br /> 3. Grantee Representative 4. Department of Health Representative <br /> Jim Miller Phone number: • Leslie Hafford Phone number: <br /> Engineering Superintendent 425.257.8880 Program Contract Manager 360.236.3083 <br /> 3200 Cedar St P.O. 47822 <br /> Everett,Washington 98201 Email address: Olympia,Washington 98504 Email address: <br /> jmiller(cci.everett.wa.us Leslie.hafford(cdoh.wa.gov <br /> 5. Grant Amount 6. Funding Source 7. Start Date 8. End Date <br /> $1,000,000.0024 months after <br /> Federal: El State: ® Other: ❑ N/A: ❑ Date of Execution Date of Execution <br /> 9. Federal Funds (as applicable) Federal Agency CFDA Number <br /> N/A N/A <br /> 10.Tax ID# 11. SWV# 12. UBI# 13. DUNS# <br /> 91-6001248 0000348-00 313-000-656 N/A <br /> 14. Grant Purpose <br /> The outcome of this performance-based agreement is to build the Everett-Tulalip Water Pipeline Segment 4, as referenced <br /> in Attachment I: Project Scope of Work. <br /> DOH, defined as the Department of Health or its successor agency, and the Grantee, as defined above, acknowledge and <br /> accept the terms of this Grant and attachments and have executed this Grant on the date below to start as of the date and <br /> year referenced above. The rights and obligations of both parties to this Grant are governed by this Grant and the following <br /> other documents incorporated by reference: Grant Terms and Conditions, Attachment I —Project Scope of Work, <br /> Attachment II —Certification of Availability of Funds to Complete the Project, Attachment III—Estimated Project Costs, <br /> Attachment IV—Certification of the Payment and Reporting of Prevailing Wages, Attachment V—Certification of Intent to <br /> Enter the Leadership in Energy and Environmental Design (LEED)Certification Process. <br /> FOR THE GRANTEE FOR THE DEPARTMENT OF HEALTH <br /> Authorized Signature Department of Health Contracting Officer Signature <br /> Print Name Print Name <br /> Title Date <br /> Date <br /> DOH Grant N19726 Page 5 of 26 City of Everett <br />