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HomeMy WebLinkAboutUntitled CITY OAK PARK HEIGHTS 14168 North 57th Street • P.O. Box 2007 • Oak Park Heights, MN 55082-2007 • Phone:651/439-4439 • Fax:651/439-0574 .'�• Post-Ir brand fax transmittal memo 7671 #of pages o• I 0 February 9, 2001 To From r: t 6 �f kv1 T .—r ot 7 7,„,,ti n f<< co. n/ "574. co.O.r k kit7 Minnesota Department of Labor and Industry Dept. Phone#GS(,H.3 q-44 sy Occupational Safety and Health Division Fax# ; 7_ Z y Z7 Fax# / _14 ATTN: Terry Mueller 443 Lafayette Road St. Paul,MN 55155-4307 Fax: 651-297=2527 Attached is the second Mandatory Progress Report. The report provides limited space for information. Therefore,I have provided a more complete explanation of the actions taken below. Citation Item: 1-1 Tower# 1 ladder safety. Compliance Date February 1, 2001, . A Petition for Modification of Abatement Date was submitted to MN OSHA on February 1, 2001 requesting February 9,2001 as new abatement date. Status: Completed February 7,2001 DBI/SALA Lad Saf Climbing systems were installed on all three ladders. Polaroid pictures were taken of the bottom and top of the first ladder,bottom, cage and top of the middle ladder and the bottom of the top ladder These pictures were scanned and enlarged printouts of these pictures are attached We have also scanned the polaroids of the electrical shut-off for the tower and the wet vac that were sent with the first progress report. These enlarged color prints show better clarity than the previous submission. If you have any questions please contact me. Sincerely, ay E. J son,PE Public Works Director Tree City U.S.A. COMPLETE D RETURN THIS FORM ITHIN 30 DAYS osha MANDATORY PROGRESS REPORT OFLAND Return to: Minnesota OSH Division For Office Use Only 443 Lafayette Road oCom lete St. Paul,Minnesota 55155 olncomplete Phone: (651) 296-2116 ❑Extension Request FAX: (651) 297-2527 In accordance with MN Rule 5210.0532,this report MUST be returned to the Area Office designated above. Failure to submit all require progress reports will result in an additional citation, penalty,and/or followup inspection.The completed Progress Report Form is to L- mailed by the latest abatement date on the citation,or within 30 days after receipt of the citation, whichever is earlier. Additional repos. (if necessary) are to be sent at 30 day intervals until all items have been fully abated. From: THO:ppAS MLENA OAKARK EIGHTS Inspection No. 1416OAK riHE ARK BLVD NTY OF OSHI ID Optional Report No. Jobsite: OAK ARK EIGHTS B7736 015-00 303889 26 (G5082-2007 , FILL IN ONE Citation Abatement Date Abated Anticipated and Item Action Taken Date on (Corrected) Completion Date No. Citation (See Note) 1-1 DBI/SALA Lad Saf ladder safety systems have been 2/1/01 2/7/01 installed on all three ladders. PMA submitted 2/1/01 PMA 2/9/0_ requesting extention to 2/9/01. • NOTE: If the anticipated completion date is beyond the date by which the alleged violation must be abated,you must submit a separa written Petition for Modification of Abatement Date (PMA)to request an extension of time allowed for completion. See the instruction for a PMA on page 2 of the Citation and Notification of Penalty. A copy of this Progress Report must be posted for 15 days where the citation and notification of penalty is posted and all affect employees and their representatives must be informed of their right to examine and copy all abatement documents submitted to t Commissioner. I hereby certify that this information is accurate. Completed by: Jay E. Johnson Title: Public Works Director Telephone: 651-439-4439 Date: February 9, 2001 (Revised 4/98) EXAMPLE ON BACK i;',.,.:,1 1 i r4 P �y ',, , i 4k 1 1. s f T h§' '*E r5, F ,ae i' '' ,;r4';',. ''': . ' ,.. ,,,i, 4,7'''*''.. 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Ili .. ,,,:,i;.:,-,:.,-,-' v� X�� �� y sG�i�� {n ya 1. �� �5 � k � k t s„�� y"yA,, �e S � S a ,./ '�' f F��d� 5: c' y 8 Ah t� y + iK a' n . 3 �}t r;ea5a�r'1J�a n e N w u 0 W Wet Vac C I TY 00 11111 ;- OAK PARK HEIGHTS t fy� 14168 North 57th Street • P.O. Box 2007 • Oak Park Heights, MN 55082-2007 • Phone:651/439-4439 • Fax: 651/439-0574 February 1, 2001 Minnesota Department of Labor and Industry Occupational Safety and Health Division ATTN: Terry Mueller 443 Lafayette Road St. Paul, MN 55155-4307 Fax: 651-296-2527 Re: Petition for Modification of Abatement Date Inspection 303889026 OSHI ID: B7736 Optional Report 01500 Citation 1 item 1 of the above referenced Citation is to install climbing safety devices on the ladders of our water tower at City Hall. We received the equipment for installation on our three ladders and have finished the installation on the first ladder. The equipment --- has been staged for installation on the other two ladders. The ice and snowstorm earlier this week delayed the project as we concentrated on clearing the streets and clogged- storm sewers. Today is the compliance date and the weather is too cold to have workers climbing metal ladders in unheated structure and performing mechanical assembly. We request an extension until Friday February 9, 2001. All other citation items have been corrected. The following are the petition items required for a PMA. 1. The action that has been taken so far to achieve compliance; DBI/SALA LadSaf ladder Safety systems have been purchased for each of the three ladders. All but two parts were received on January 24, 2001. The missing parts were for climbing,not needed for installation, and were received on the January 30, 2001. The first ladder safety system was installed on January 29, 2001. The remaining ladder safety systems were to be installed between January 30 and February 1. Weather conditions required our crews to plow city streets and open plugged storm sewers during on January 30 and 31. The installation was then scheduled for February 1, 2001. Today's extreme cold temperature makes the installation in an unheated structure unsafe. 2. The amount of additional time needed for compliance; We are requesting and extension until next Friday February 9th. The weather hopefully,will moderate back into the teens or twenties. Tree City U.S.A. - _ • 1110 3. The reason why the additional time is needed; Weather conditions required our crews to plow city streets and open plugged stormsewers during January 30 and 31. The installation was then scheduled for February 1, 2001. Today's extreme cold temperature makes the installation in an unheated structure unsafe. 4. A description of the interim steps that will be taken to safeguard employees against the cited hazard; Climbing of these ladders is very infrequent. The only foreseeable reason for climbing during the next week will be to install the ladder safety system. Both of the remaining ladders have cages,but are in excess of 30 feet in length. During the construction or any other climb the worker will use an "EZ Stop II" shock absorbing lanyard and safety harness to attach the climber to the ladder during the climb. The worker will attach the lanyard to the ladder then climb three steps and attach the harness front "D" ring to the ladder while moving the lanyard to the above him. Using this method the climber will always be attached to the ladder during climbing. 5. ' A statement that employees have been notified of the PMA filing. All personnel who authorized to climb the tower have been notified of the filing of the PMA. The persons notified are Jay Johnson, Public Works Director, Jeff Kellogg, _ Public Works Foreman,and Roland Staberg,Utility Worker . I apologize for the lateness of this petition, if it were ten degrees warmer(as had been predicted earlier this week)we would have been able to install the systems today. Thank you for your consideration. Sincerely; ay E. ohnson, P.E. Public Works Director CITY AO • R`_, ,, OAK PARK HEIGHTS �a 14168 North 57th Street • P.O. Box 2007 • Oak Park Heights, MN 55082-2007 • Phone:651/439-4439 • Fax:651/439-0574 February 1, 2001 Minnesota Department of Labor and Industry Occupational Safety and Health Division ATTN: Terry Mueller 443 Lafayette Road St. Paul, MN 55155-4307 Fax: 651-297-2527 f U X vl r11 , Attached is the first Mandatory Progress Report. The report provides limited space for information. Therefore,I have provided an more complete explanation of the actions taken below. Paragraph 2 of the Expedited Settlement Agreement specifies that the progress report is due 30 days after the issuance of the citation and every thirty days until the items are abated.. The citation date was January 4, 2001. This report is within the first thirty days period. The following are citation items and their status. Citation Item: 1-1 Tower# 1 ladder safety. Compliance Date February 1, 2001 The tower ladders were found require additional safety devices. To comply with this requirement DBI SALA LadSaf Ladder Safety Systems are to be installed on all three ladders. This is the same system as used in Tower#2 and therefore will not require additional training in the use of the system. The system consists of a cable supported in the middle of the ladder, a climbing harness and a climbing sleeve. The sleeve attaches to the harness and the cable. The sleeve is designed to free slide up the cable but locks whenever the harness pulls downward against the cable. Status: Three LadSaf systems were ordered for delivery on January 19, 2001. Actual receipt of the systems was on January 25, 2001. First ladder installed on January 30, 2001. Due to weather other two ladder installation is delayed. A Petition for Modification of Abatement Date was submitted to MN OSHA on February 1, 2001 requesting February 9, 2001 as new abatement date. Citation Item 1-2 Eyewash station not provided where caustic chemicals are used for fluoride analysis. Compliance Date January 18, 2001. Status: Abated January 12, 2001. The eyewash station was received and placed in service. Tree City U.S.A. • • Citation Item 1-3 Compressed air used for cleaning was not reduced to 30 psi. Compliance Date January 10, 2001 The airgun used for cleaning has a maximum inlet pressure of 150 psi with the outlet pressure reduced to 30 psi maximum nozzle pressure. It also has a non-plugging tip. Prior to the inspection the airgun had last been used to cleanout sewer lift station bubbler lines and still had the rubber cover over the non plugging tip. This attachment is only to be used with bubbler lines and is not to be used for cleaning. With the rubber cover removed and the non-plugging tip cleaned the nozzle pressure has been tested at 22 to 25 psi. An older airgun that does not have the pressure reducing device and the non-plugging tip was found in the garage. This older airgun has been plugged with silicon caulk and will be used as an example of an improper device in safety training programs. Copy of gun is attached showing the pressure rating is attached. A safety procedure (including training) on use of compressed air and compressed fluids will be written and implemented. Status: Abated December 6, 2000 Citation 1-4 Ground plug for wet vac was missing. Compliance Date January 10,2001 Status: Abated Plug replaced December 8,2000. December 8, 2000. In addition we have reviewed other power equipment and made repair or removed the items from service as needed: This included two typewriters which needed polarized plugs,two hand drills with frayed wiring (removed from service) and the plug on the compressor. Other electrical safety actions taken include increasing the use of GFI plugs at our park facilities as a continuation of the facility updates started last year. Citation 1-5 Electrical switch on a post by water tower#1 was not in a secured enclosure and was not weatherproof. Compliance Date January 18,2001. Status: Abated January 11, 2001. The power shutoff switch for the tower has been secured with a padlocked. Linner Electric has filled the opening on the bottom of the box. Pictures attached. According to the electrician from Linner Electric this box meets electrical codes. The City Engineer has reported that the water tower is considered a separate structure and requires a separate shut-off. It can be located inside or outside the tower where the power enters the structure. Recommendation: This spring we should install new wiring from the building to the tower. This wiring should be in conduits with separate conduits for communications and power. The shutoff should be located inside of the tower. Citation 1-6 Employer did not implement Right To Know training for employees exposed to hazardous substances. Compliance Date February 1,2001. 2 • • Status: Abated 1/30/01 Hazard evaluation complete. Training program completed January 30, 2001. Training records filed in personnel records and Safety Coordinator files. Additional training will be ongoing with monthly classes providing updates on subjects such as cold weather operations, .hot weather operations, safe use of hydraulic/pneumatic systems,confined space entry, hearing conservation, respiratory protection, etc. Sincerely: Jay E. Johnson, PE • Public Works Director ENCL: Mandatory Progress Report Various Pictures • 3 COMPLETE • D RETURN THIS FORM 'ITHIN 30 DAYS osha of��� MANDATORY PROGRESS REPORT Return to: Minnesota OSH Division For Office Use Only 443 Lafayette Road oComplete St. Paul,Minnesota 55155 ❑Incomplete Phone: (651) 296-2116 °Extension Request FAX: (651) 297-2527 In accordance with MN Rule 5210.0532,this report MUST be returned to the Area Office designated above. Failure to submit all require: progress reports will result in an additional citation, penalty,and/or followup inspection.The completed Progress Report Form is to t;= mailed by the latest abatement date on the citation, or within 30 days after receipt of the citation,whichever is earlier. Additional report:: (if necessary) are to be sent at 30 day intervals until all items have been fully abated. From: THOMAS MELENA OAK PARK HEIGHTSInspection No. 14168 OAK rtrH.ET3I.VkliNN' CITY OF OSHI ID Optional Report No. Jobsite: AK PARK 55082-2007 67736 015-00 303889026 (GI) • - FILL IN ONE Citation Abatement Date Abated_ Anticipated and Item Action Taken Date on (Corrected) Completion Date No. Citation (See Note) 1-1 DBI Sala Ladsaf Ladder Safety Systemshave been received. One installed. PMA submitted 2-1-01. 2-1-01 PMA 2/1/01 2/9/01 1-2 Eyewash Station Installed. 1-18-01 1/12/01 1-3 kir gun has internal regulator for 30psi nozzle pressure (Picture Attached) 1-10-01 12/6/00 1-4 Plug on wet vac replaced (Picture Attached) 1-10-01 12/8/00 1-5 Lock Added -Linner Electric caulked bottom knock-out (Pictures Attached) 1-18-01 1/if/01 1-6 MERTK Program Implemented. Training Class 1/30/01 2-1-01 1./30/01 NOTE: If the anticipated completion date is beyond the date by which the alleged violation must be abated,you must submit a separa written Petition for Modification of Abatement Date (PMA)to request an extension of time allowed for completion. See the instructor for a PMA on page 2 of the Citation and Notification of Penalty. A copy of this Progress Report must be posted for 15 days where the citation and notification of penalty is posted and all affect employees and their representatives must be informed of their right to examine and copy all abatement documents submitted to t Commissioner. I hereby certify that this information is accurate. Completed by: Jay E. Johnson Z : Public Works Director Telephone: (651) 439-4439 Date: February 1, 2001 (Revised 4/98) EXAMPLE ON BACK • • Ce-Lf Cr Loticv.u\- \3. vit)A.. w t-Tut.' .v 3�J 2k� - -� � �,,., mac : ►'�� ^3 J , , frk Its \'a SSSSSS....SSSS ,,,,,,,,,,,,,,,,,,,,, 40 • /t.,,, 9.,..,14, or .t.....* i i...2.,__,_-, : i Minnesota `=a �it Department of Labor and Industry % �Y) '` Occupational �''••;}',�';��18�}�;;,,.••'' p Safety and Health Division In the matter of: Oak Park Heights, City of INSPECTION NO.: 303889026 OSHI ID/OPTIONAL REPORT NO: B7736 015-00 EXPEDITED INFORMAL SETTLEMENT AGREEMENT (Oak Park Heights,City of),by its undersigned representative and Minnesota Occupational Safety and Health Division(MNOSHA)by its undersigned representative, in settlement of the above referenced Citation and Notification of Penalty(CITATION),hereby agree to the disposition of this matter on the following terms: 1. The EMPLOYER agrees to abate the violations as cited, on or before the abatement dates set out in the CITATION. 2. The EMPLOYER agrees to provide evidence of the actions taken to abate the violations by submitting written progress reports to MNOSHA within 30 days of citation issuance and every 30 days thereafter until all items are abated. 3. Upon correction of all violations,the EMPLOYER agrees to post for a period of three days a copy of the final progress report certifying that all violations have been abated in the place where the CITATION is posted. 4. MNOSHA agrees that the total penalty amount is amended to($1,312.00). The EMPLOYER agrees to submit full payment of the amended amount along with this original signed Settlement agreement within 20 days following the EMPLOYER'S receipt of the CITATION. 5. In consideration of the foregoing amendment,the EMPLOYER hereby waives its right to contest the CITATION pursuant to MN Statutes § 182.661. It is understood and agreed by MNOSHA and the EMPLOYER that the CITATION as amended by this agreement shall be deemed a fmal order of the Commissioner not subject to review by any court or agency. 6. The EMPLOYER agrees to immediately post a copy of this Settlement Agreement in the same manner and place as the CITATION is required to be posted. The signature of the EMPLOYER representative on this Settlement Agreement is understood to be certification of this posting. 7. In addition to action MNOSHA may take against the EMPLOYER pursuant to Minn. Stat. Ch. 182 (1996)and other remedies provided by law,the EMPLOYER agrees that its failure to comply with any term of this agreement shall cause the original penalty amount of($1,875.00) to become due and owing to MNOSHA. • • Expedited Informal Settlement Agreement Page 2 • 8. Each party hereby agrees to bear its own fees and other expenses incurred with this proceeding and the EMPLOYER further agrees to waive all claims it may have, now and in the future, under MN Statutes §15.472 for fees and expenses arising out of this case. 44-/--?:1"41‘2-% EMPLOYER Representative MNOSHA epresentative C�'`�� OMT Director Title Title \ , ` \ L \ 0 I Date Signed Date Signed NOTICE TO EMPLOYEES Any employee or authorized employee representative who has an objection to the above referenced Citation and Notification of Penalty may contest the citation within 20 calendar days of the employer's receipt of it,in accordance with the instructions on page 3 of the Citation and Notification of Penalty. In addition, any employee or authorized employee representative who has an objection to the Citation and Notification of Penalty as amended by this agreement may contest the amended citation within 20 calendar days of the posting of this Settlement Agreement. ., l ,,,. i ^yQv:�otLL Du :.\ 1,4i ...,,A *- =*" Minnesota 'i:;---:::9, _� ,:_ Department of Labor and Industry t Occupational Safety and Health Division In the matter of: Oak Park Heights, City of INSPECTION NO.: 303889026 OSHI ID/OPTIONAL REPORT NO:B7736 015-00 EXPEDITED INFORMAL SETTLEMENT AGREEMENT (Oak Park Heights,City of),by its undersigned representative and Minnesota Occupational Safety and Health Division(MNOSHA) by its undersigned representative, in settlement of the above referenced Citation and Notification of Penalty (CITATION),hereby agree to the disposition of this matter on the following terms: 1. The EMPLOYER agrees to abate the violations as cited, on or before the abatement dates set out in the CITATION. 2. The EMPLOYER agrees to provide evidence of the actions taken to abate the violations by submitting written progress reports to6MNOSHA within 30 days of citation issuance and every 30 days thereafter until all items are abated. 3. Upon correction of all violations,the EMPLOYER agrees to post for a period of three days a copy of the final progress report certifying that all violations have been abated in the place where the CITATION is posted. 4. MNOSHA agrees that the total penalty amount is amended to($1,312.00). The EMPLOYER agrees to submit full payment of the amended amount along with this original signed Settlement agreement within 20 days following the EMPLOYER'S receipt of the CITATION. 5. In consideration of the foregoing amendment,the EMPLOYER hereby waives its right to contest the CITATION pursuant to MN Statutes § 182.661. It is understood and agreed by MNOSHA and the EMPLOYER that the CITATION as amended by this agreement shall be deemed a final order of the Commissioner not subject to review by any court or agency. 6. The EMPLOYER agrees to immediately post a copy of this Settlement Agreement in the same manner and place as the CITATION is required to be posted. The signature of the EMPLOYER representative on this Settlement Agreement is understood to be certification of this posting. 7. In addition to action MNOSHA may take against the EMPLOYER pursuant to Minn. Stat. Ch. 182 (1996)and other remedies provided by law,the EMPLOYER agrees that its failure to comply with any term of this agreement shall cause the original penalty amount of($1,875.00) to become due and owing to MNOSHA. 1111 • Expedited Informal Settlement Agreement Page 2 8. Each party hereby agrees to bear its own fees and other expenses incurred with this proceeding and the EMPLOYER further agrees to waive all claims it may have, now and in the future, under MN Statutes §15.472 for fees and expenses arising out of this case. EMPLOYER Representative MNOSHA epresentative '^'``� ' OMT Director Title ' Title Date Signed Date Signed NOTICE TO EMPLOYEES Any employee or authorized employee representative who has an objection to the above referenced Citation and Notification of Penalty may contest the citation within 20 calendar days of the employer's receipt of it,in accordance with the instructions on page 3 of the Citation and Notification of Penalty. In addition, any employee or authorized employee representative who has an objection to the Citation and Notification of Penalty as amended by this agreement may contest the amended citation within 20 calendar days of the posting of this Settlement Agreement. II • � ,••....... .. o,L.„„, .... •••.,� �'• ay� Q�ti�` Minnesota :, ��� Department of Labor and Industry ,,1a �� ',.?li... .::-•' '. Occupational Safety and Health Division In the matter of: Oak Park Heights, City of INSPECTION NO.: 303889026 OSHI ID/OPTIONAL REPORT NO: B7736 015-00 EXPEDITED INFORMAL SETTLEMENT AGREEMENT (Oak Park Heights,City of),by its undersigned representative and Minnesota Occupational Safety and Health Division(MNOSHA)by its undersigned representative, in settlement of the above referenced Citation and Notification of Penalty(CITATION),hereby agree to the disposition of this matter on the following terms: 1. The EMPLOYER agrees to abate the violations as cited, on or before the abatement dates set out in the CITATION. 2. The EMPLOYER agrees to provide evidence of the actions taken to abate the violations by submitting written progress reports to MNOSHA within 30 days of citation issuance and every30 days thereafter until all items are abated. 3. Upon correction of all violations,the EMPLOYER agrees to post for a period of three days a copy of the final progress report certifying that all violations have been abated in the place where the CITATION is posted. 4. MNOSHA agrees that the total penalty amount is amended to($1,312.00). The EMPLOYER agrees to submit full payment of the amended amount along with this original signed Settlement agreement within 20 days following the EMPLOYER'S receipt of the CITATION. 5. In consideration of the foregoing amendment,the EMPLOYER hereby waives its right to contest the CITATION pursuant to MN Statutes § 182.661. It is understood and agreed by MNOSHA and the EMPLOYER that the CITATION as amended by this agreement shall be deemed a final order of the Commissioner not subject to review by any court or agency. 6. The EMPLOYER agrees to immediately post a copy of this Settlement Agreement in the same manner and place as the CITATION is required to be posted. The signature of the EMPLOYER representative on this Settlement Agreement is understood to be certification of this posting. 7. In addition to action MNOSHA may take against the EMPLOYER pursuant to Minn. Stat. Ch. 182 (1996)and other remedies provided by law,the EMPLOYER agrees that its failure to comply with any term of this agreement shall cause the original penalty amount of($1,875.00) to become due and owing to MNOSHA. • Expedited Informal Settlement Agreement Page 2 8. Each party hereby agrees to bear its own fees and other expenses incurred with this proceeding and the EMPLOYER further agrees to waive all claims it may have, now and in the future, under MN Statutes §15.472 for fees and expenses arising out of this case. \r\r, // EMPLOYER Representative MNOSHA •epresentative "�'``� OMT Director Title Title ‘A. Date Signed Date Signed • NOTICE TO EMPLOYEES Any employee or authorized employee representative who has an objection to the above referenced Citation and Notification of Penalty may contest the citation within 20 calendar days of the employer's receipt of it, in accordance with the instructions on page 3 of the Citation and Notification of Penalty. In addition,any employee or authorized employee representative who has an objection to the Citation and Notification of Penalty as amended by this agreement may contest the amended citation within 20 calendar days of the posting of this Settlement Agreement. • OP ,,,,,....till.a...., ,., off• S?9T�.,,, Minnesota Department of Labor and Industry ,J v•�,toILEDUA•DR'•.�,,, z... •.D,,4 Occupational Safety and Health Division sa ‘ ..:. '1Y,16`0" t[l 1858 Subject: CITATION AND NOTIFICATION OF PENALTY for Alleged Occupational Safety and Health Violations and Eligibility for Expedited Informal Settlement Agreement(EISA) A recent inspection of a place of employment under your operation, ownership, or control has resulted in the enclosed Citation and Notification of Penalty which describes alleged violations of the Minnesota Occupational Safety and Health Act of 1973. Please read carefully and follow instructions listed under EMPLOYER AND EMPLOYEE RIGHTS AND RESPONSIBILITIES on the citation and the following discussion of your eligibility for an EISA. This inspection revealed no instances of Repeated,Willful,or Failure-to Abate violations,nor were there more than two high gravity Serious violations. Additionally, the Occupational Safety and Health Investigator has reported that you have a good understanding of the actions necessary to correct the violations that were cited,and that you are willing to make those corrections by the dates specified in the Citation and Notification of Penalty. These factors, along with the good faith you have exhibited, make your company eligible for an Expedited Informal Settlement Agreement (EISA). Under this program, an employer can obtain a 30 percent penalty reduction by entering into an informal settlement agreement with MNOSHA, without going through the formal contestation procedure. However,if you decide to enter into an Expedited Informal Settlement Agreement,you should be aware that you waive your right to contest any part of the Citation and Notification of Penalty. You cannot both contest a portion of the Citation and Notification of Penalty and obtain an EISA on the remaining portion. The EISA can be used only where the sole issue of dispute is the dollar amount of the MNOSHA penalty. If you wish to discuss,change,or object to any other aspect of the inspection or citations, then the EISA cannot be used. Under those circumstances, you may file a notice of contest according to the instructions contained on the Citation and Notification of Penalty and the attached Notice of Contest form. Aik Your F ,. fully read the enclosed EISA to determine whether the terms of the agreement are aceepta ,_tou. Key elements of the agreement include: - iMNIA agrees to a 30%reduction in the total penalty amount; The employer agrees to post the EISA with the citation; The employer agrees to abate the violations by the date shown in the citations(an employer acting in good faith may request an extension of the original abatement date); The employer agrees to provide evidence of corrective action and submit a written progress report to MNOSHA within 30 days of citation issuance and every 30 days thereafter until all items are abated; The employer agrees to pay the full amount of the reduced penalty at the time that the original signed EISA is returned to MNOSHA. The original signed EISA and payment of reduced penalty(70% of the total original penalty amount)must be received by MNOSHA within 20 calendar days following your receipt of the Citation and Notification of Penalty. Written progress reports must be submitted to MNOSHA to show that you have completed all corrections as of the "date by which the violation must be abated" shown on the citation. You should be aware that Federal OSHA publishes information on its inspection and citation activity on the Internet under the provisions of the Electronic Freedom of Information Act. The information related to your inspection will be available 30 calendar days after the Citation Issuance Date. You are encouraged to review the information concerning your establishment at WWW.OSHA.GOV. If you have any dispute with the accuracy of the information displayed,please contact this office. If you have any questions regarding the citation or this Expedited Informal Settlement Agreement offer,please contact me at(651)296-2116. Sincerely, Terry Mueller OMT Director COMPLETE MD RETURN THIS FORM THIN 30 DAYS osha MANDATORY PROGRESS REPORT Return to: Minnesota OSH Division For Office Use Only 443 Lafayette Road oComplete St. Paul,Minnesota 55155 ❑Incomplete °Extension Request Phone: (651) 296-2116 FAX: (651) 297-2527 In accordance with MN Rule 5210.0532,this report MUST be returned to the Area Office designated above. Failure to submit all require' progress reports will result in an additional citation, penalty,and/or followup inspection.The completed Progress Report Form is to be mailed by the latest abatement date on the citation, or within 30 days after receipt of the citation,whichever is earlier. Additional reports (if necessary) are to be sent at 30 day intervals until all items have been fully abated. From: THOMAS MELENA Inspection No. OAK PARK HEIGHTS, CITY OF OSHI ID 14168 OAK PARK BLVD N Optional Report No. Jobsite: OAK PARK H E;G H rS M 55082-2007 87736 015-00 303889026 (GI) FILL IN ONE Citation Abatement Date Abated Anticipated and Item Action Taken Date on (Corrected) Completion Date No. Citation (See Note) NOTE: If the anticipated completion date is beyond the date by which the alleged violation must be abated,you must submit a separate written Petition for Modification of Abatement Date (PMA)to request an extension of time allowed for completion. See the instruction for a PMA on page 2 of the Citation and Notification of Penalty. A copy of this Progress Report must be posted for 15 days where the citation and notification of penalty is posted and all affect, employees and their representatives must be informed of their right to examine and copy all abatement documents submitted to t Commissioner. I hereby certify that this information is accurate. Completed by: Title: Telephone: Date: (Revised 4/98) EXAMPLE ON BACK COMPLETE A* RETURN THIS FORM WIN 30 DAYS 11 osha MANDATORY PROGRESS REPORT DEPARTIENT cc u AND INDUSTRY I`<>;:><:.,.:::::.<:>1 For Office Use Only Return to: innesota OSH Division -.:,, >.:::>::>� ❑Complete + 43a�ayette Road leteIncom Vii. Paul, Minnesota 55155 ❑ p I:>= i:x:i:>:<«>*il ❑Extension Request Telephone: 651/296-2116 Fax: 651/297-2527 In accordance with MN Ru >. 21 ::Q: ?532, this report MUST be returned to the Area Office designated above. Failure to submit all required progress reports wi >., stilt in an additional citation, penalty, and/or followup inspection. The completed Progress Report Form is to be mailed by th >a\est abatement date on the citation, or within 30 days after receipt of the citation, whichever is fie:;: earlier. Additional reports:., a _ ssary) are to be sent at 30 day intervals until all items have been fully abated. From: Company Name Company Address Inspection No. 300000000 City, State Zip OSHI ID: S9999 .... Jobsite: Optional Report No. 001-98 i::. FILL IN ONE Citation Actionaken Abatement Date Anticipated and Item Date on Abated Completion Date No. Citation (Corrected) (See Note) 1-1 Safety goggle eye protection has been provided to workers in 7/10 7/6 washer area. liki 111. 1-2 Fan removed from site; no longer available U. 7/10 7/3 1-3 Shower/eyewash station installed 8/10 8/2 2-1 Right-to-Know program written 7/21 7/17 a. MSDSs consolidated; missing MSDSs requested from mfrs 8/10 9/1 b. training program updated and being conducted by departrnert.:::*i:> 8/10 9/1 c. training records updated; maintenance system established d ..?) 7/17 d. training will be conducted for all new employees upon hire' , «::%:"' 7/21 7/17 iti 2-2 Respirator removed from work area and no longer available for use; 7/21 7/3 written respirator program no longer required. NOTE: If the anticipated completion date is beyond the date by which the alleged violation must be abated, you must submit a separate written Petition for Modification of Abatement Date (PMA) to request an extension of time allowed for completion. See instructions for a PMA on page 2 of the Citation and Notification of Penalty. ig iiiii A copy of this Progress Report must be posted for 15 days where the citation and notific.:ion of penalty is posted and all affected employees and their representatives must be informed of their right to examine and co`' all abatement documents submitted to the Commissioner. I hereby certify that this information is accurate. Completed by: Title: ITelephone: Date: :1 (Revised 4/98) l_ :>::::::::>:::_<;:>.I Minnesota • . Inspection Number: 1111 Department of Labor and Industry OSHI ID: Optional Report No.: Occupational Safety and Health Division 443 Lafayette Road Employer's Name and Mailing Address St. Paul, MN 55155-4307 Phone: (651)296-2116 FAX: (651)297-2527 NOTICE OF CONTEST AND SERVICE TO AFFECTED EMPLOYEES PURPOSE OF THIS FOR\' This Notice of Contest and Service to Affected Employees form (Notice of Contest form) should ONLY be completed by an employer who has received a Citation and Notification of Penalty from the Minnesota Occupational Safety and Health Division (MNOSHA), who wishes to contest that a violation occurred, the type of violation, the proposed penalty and/or the date by which the violation must be abated. If the employer only wishes to obtain an extension of time to abate the violation, the employer may file a Petition for Modification of Abatement Date according to the instructions on the Citation and Notification of Penalty. By filing this Notice of Contest form, the employer is initiating a formal contested case proceeding before an administrative law judge of the parts of the Citation and Notification of Penalty it is contesting. This form must be filed in good faith and not solely for delay or avoidance of penalties. Upon receipt of a timely filed Notice of Contest form, MNOSHA will contact the employer and schedule a date, time and location for an informal conference. The purpose of the informal conference is to allow the employer to discuss with a MNOSHA representative the Citation and Notification of Penalty and the basis for the employer's contest. The goal of the informal conference is to reach an early informal resolution of the contest. If the employer and MNOSHA are unable to reach a resolution at the informal conference then the contest will proceed to a formal contested case hearing.' FILING THIS FORM This Notice of Contest form must be filed with the Commissioner of the Department of Labor and Industry at the above address within 20 days after the date the Citation and Notification of Penalty is received by the employer. To be considered filed, all parts of the Notice of Contest form must be completed and the completed form must be deposited in the United States mail and postmarked, or otherwise timely received by the Commissioner at the above address within 20 days after the date the Citation and Notification of Penalty is received by the employer. Facsimile (FAX) transmittal of this form is acceptable, followed by receipt of the mailed original within 5 days. If the employer fails to file the Notice of Contest form on time, the Citation becomes a final order of the Commissioner which is not subject to review by any court or agency. COMPLETING THIS FORM 1. HOW TO IDENTIFY THE INSPECTION BEING CONTESTED. The employer must complete the box at the top of page 1 of this form using the Inspection Number, OSHI ID, Optional Report Number and Employer's Mailing Address from the Citation and Notification of Penalty being contested. 2. HOW TO POST AND SERVE THIS FORM. The employer must post a fully completed copy of both pages of this form where the contested Citation and Notification of Penalty is posted no later than the last day this form may be filed. The form must remain posted until the date of the formal contested case hearing or earlier final resolution of the contest. If there are any affected employees who are represented by an authorized employee representative, the employer shall, on or before the date this form is required to be filed with the Commissioner, serve a fully completed copy of the form upon the representative. Service may be accomplished by either postage prepaid first class mail or personal delivery. (Revised 8/97) 3. DATE OF POSTING. The employe ust certify in Box A or B below the data,which it posted and served this form. A. Employers who have.affected Employees B Employers who have affected Employees Not. Represented By Authorized Employee Represented by Authorized Employee Representatives (union) Representatives:. . I hereby certify that I posted fully completed copies I hereby certify that I posted fully completed copies of this form on / / (date) of this form on / / (date) at the locations where the Citation and Notification at the locations where the Citation and Notification of Penalty is posted; and I served fully completed of Penalty is posted and that I do not have any copies of this form on / / (date) affected employees who are represented by upon the authorized employee representatives of authorized employee representatives. affected employees. 4. HOW TO CONTEST THE CITATION AND NOTIFICATION OF PENALTY. The employer must indicate in the boxes below which part of the Citation and Notification of Penalty it wishes to contest. First the employer must identify the citations it is contesting by indicating the citation and item numbers. (For example, "Citation 1, Item 2"). Then the employer must indicate which parts of each item is being contested. Finally, the employer must state the reasons for contesting in the space provided below the boxes. • Check the box under the heading CITATION, if the employer wishes to contest that the violation occurred. • Check the box under the heading TYPE OF VIOLATION, if the employer wishes to contest the characterization of the violation as non-serious, serious, willful or repeat. • Check the box under the heading ABATEMENT DATE, if the employer wishes to contest the date by which you must abate the violation. • Check the box under the heading PENALTY, if the employer wishes to contest the amount of the penalty. FAILURE TO CHECK ANY PART WILL RESULT IN THAT PART OF THE CITATION BECOMING A FINAL ORDER OF THE COMMISSIONER WHICH IS NOT.REVIEWABLE BY ANY COURT OR AGENCY. CITATION CITATION TYPE OF ABATEMENT PENALTY VIOLATION DATE AND ITEM NUMBER I contest that a I contest the I contest the I contest the Violation occurred Type of Violation Abatement Date Amount of the Penalty REASONS FOR CONTEST: (additional sheets may be attached as necessary) 5. OATH The employer completing this form must sign and have notarized the following statement. I SWEAR THAT THE INFORMATION PROVIDED ON THIS FORM AND ATTACHED TO THIS FORM IS ACCURATE AND TRUTHFUL TO THE BEST OF MY KNOWLEDGE. Subscribed and sworn to before me this date of , 19_ Name of Employer Representative Title Notary Public ( ) My Commission expires ,19_ Phone Signature Date • Minnesota Department of Labor and Industry °'�. ., Occupational Safety and Health Division 443 Lafayette Road Vii;ss St. Paul, MN 55155-4307 __. _ ti Phone: (651)296-2116 FAX: (651) 297-2527 Citation and Notification of Penalty To: Inspection Number: 303889026 Oak Park Heights, City of OSHI ID: B7736 14168 Oak Park Blvd. No. Optional Report No.: 01500 Oak Park Heights, MN 55082-2007 Inspection Date(s): 12/06/2000 - 12/06/2000 Issuance Date: 01/04/2001 Inspection Site: 14168 Oak Park Blvd. No. The:violatton(s)described in this Citation and Notification Oak Park Heights, MN 55082-2007 of Penalty is (are)alleged to have occurred on or about the days) the inspection was made;unless otherwise indicated within the description given below. This Citation and Notification of Penalty (this Citation) describes violations of the Minnesota Occupational Safety and Health Act of 1973 (the Act). The penalty amounts listed herein are based on these violations. You must abate the violations referred to in this Citation by the dates listed and pay the penalties, unless within 20 calendar days from your receipt of this Citation you file a Notice of Contest with the Commissioner of the Department of Labor and Industry. Your contestation rights and other employer and employee rights and responsibilities are set out in the first three pages of this Citation. The description of alleged violations begins on page 4 of this Citation. EMPLOYER AND EMPLOYEE RIGHTS AND RESPONSIBILITIES Posting - The Act requires that a copy of this Citation shall be promptly posted at or near each place that an alleged violation referred to in the citation occurred. If uncontested, this Citation must remain posted until all alleged violations cited therein are corrected, or for 20 days, whichever is longer. If contested, this Citation must remain posted until the contestation is resolved. Penalty Payment- Payment of all penalties is to be made by check or money order payable to "Minnesota Department of Labor and Industry" and remitted to the Occupational Safety and Health Division at the address above within 20 calendar days following receipt of this Citation. After 60 days, unpaid penalties shall increase 25 percent and shall accrue an additional interest of 10 percent per month compounded monthly until the fine is paid in full. Citation and Notification of Penalty Page 1 of 10 MNOSHD-2 (Rev. 1/95) i • Notification of Corrective Action - Progress reports on correction of alleged violations not immediately abated shall be submitted on the Progress Report form provided with this Citation. Written progress reports must be submitted to the Area Office indicated in the cover letter accompanying this Citation within 30 calendar days of the issuance date. Reports must state the specific corrective action taken on each cited item, the date of such action and the anticipated abatement date of uncompleted items. Additional written progress reports shall be submitted every thirty days until the items are fully abated. Facsimile (FAX) transmittal is acceptable. All alleged violations not contested must be corrected by the abatement date specified in this Citation. A followup inspection may be made for the purpose of ascertaining that the employer has corrected the alleged violations and posted this Citation as required by the Act. Failure to correct an alleged violation by the abatement date on this Citation may result in further penalties for each day the alleged violation has not been corrected. Petition for Modification of Abatement Date (PMA) - If, due to factors beyond reasonable control, compliance cannot be achieved by the abatement day on the citation, the employer may file a Petition for Modification of Abatement Date (PMA) to obtain an extension of the abatement time period. The PMA must be in writing and received by the Area Office at the address indicated in the cover letter prior to the expiration of the abatement date on the citation. Facsimile (FAX) transmittal of a PMA is acceptable. A copy of the PMA must be posted for ten days in the location where this Citation is posted. A copy of the PMA must also be served upon authorized employee representatives. The employer's written petition must describe: 1) The action that has been taken so far to achieve compliance; 2) The amount of additional time needed for compliance; 3) The reasons why additional time is needed; 4) A description of the interim steps that will be taken to safeguard employees against the cited hazard; 5) A statement that employees have been notified of the PMA filing. Employees have the right to file a written objection to the Commissioner regarding the employer's PMA request. A copy of the objection must be served on the employer within 10 days of the employer's posting of the PMA. The employee objection must be received by the Commissioner within 15 days of the employer's PMA request. Facsimile (FAX) transmittal is acceptable. Employer Right to Contest - The employer has the right to a hearing to contest any or all parts of this Citation. If the employer wishes to contest, the employer must fully complete and notarize the attached NOTICE OF CONTEST AND SERVICE TO AFFECTED EMPLOYEES (Notice of Contest form) and file it with the Commissioner at the address shown on page 1 of this Citation within 20 calendar days of receiving the citation. Important: To be considered filed, all parts of the Notice of Contest form must be completed and the completed form must be deposited in the United States mail and postmarked, or otherwise timely received by the Commissioner at the above address within 20 days after the date this Citation is received by the employer. Facsimile (FAX) transmittal is acceptable, followed by the mailed original within 5 days. If the employer fails to file the Notice of Contest form on time, this Citation and Notification of Penalty becomes a final order of the Commissioner which is not subject to review by any court or agency and the Occupational Citation and Notification of Penalty Page 2 of 10 MNOSHD-2(Rev. 1/95) 1111 • Safety and Health Division may file and enforce the penalty as a district court judgment without further notice or additional proceedings pursuant to Minnesota Statutes 16D.17. Employee Right to Contest - An employee or authorized representative of employees has the right to a hearing to contest this Citation by filing a letter with the Commissioner of the Department of Labor and Industry at the address shown on page 1 within 20 calendar days of the employer's receipt of this Citation. Important: To be considered filed, an employee letter of contest must be depostied in the United States mail and postmarked, or otherwise timely received by the Commissioner at the above address within 20 days after the date this Citation is received by the employer. Facsimile(FAX)transmittal is acceptable, followed by the mailed original within 5 days. If the employee fails to file a letter of contest on time, this Citation and Notification of Penalty becomes a final order of the Commissioner which is not subject to review by any court or agency and the Occupational Safety and Health Division may file and enforce the penalty as a district court judgment without further notice or additional proceedings pursuant to Minnesota Statutes 16D.17. Employee Right to Party Status - Affected employees or their authorized employee representatives may elect to participate as parties in the formal contested case hearing before the start of the hearing by filing written notice with the Commissioner at the address shown above. The notice must contain the employees' names, addresses, authorized employee representatives, if any, and a statement that they are affected employees of the cited employer. Employer Discrimination Unlawful-Employees who believe that they have been discharged or otherwise discriminated against by any person because the employees have exercised any right authorized under the provisions of Minnesota Statute§ 182.674, may, within 30 days after such alleged discrimination occurs, file a complaint with the Commissioner of the Department of Labor and Industry at the address shown above, alleging the discriminatory act. Citation and Notification of Penalty Page 3 of 10 MNOSHD-2(Rev. 1/95) M • Minnesota Inspection Number: 303889026 .�•..,, Department of Labor and Industry Inspection Dates: 12/06/2000 - 12/06/2000 Occupational Safety and Health Division Issuance Date: 01/04/2001 = ' ;y T CSHO ID: B7736 Optional Inspection Nbr: 01500 Citation and Notification of Penalty Company Name: Oak Park Heights, City of Inspection Site: 14168 Oak Park Blvd. No., Oak Park Heights, MN 55082-0007 Citation 1 Item 1 Type of Violation: Serious 29 CFR 1910.27(d)(2): Fixed ladder(s)used to ascend to heights exceeding 20 feet, and where cages or wells were not provided, were not provided with a landing platform for each 20 feet of height or fraction thereof: Employees ascend and descend fixed ladders inside water tower#1 which extend 24 ft., 76 ft. and 35 ft. vertically and do not contain the required number of landing platforms or any other related ladder safety devices. .�'j�}iiii::iiiiiiiiiiiii;:i;:iji::;{.';:;{:}:;:>;:yyj.'•iiiiiiiii ij;::;:;:;:•,:;:ii;`viii ii;:i;:;:i;:;:$iii;:ii;:}:^iiiiiiiiiiiiii:•:::iii:•i:•:vi:•:•i:•i:•ii:•ivii:• :i:::::;:;:iii'riiii;:;}}:i i'r.'•ii:i�• • rte.. �kC See pages 1 through 3 of this Citation and Notification of Penalty for information on employer and employee rights and responsibilities. Citation and Notification of Penalty Page 4 of 10 MNOSHD-2(REV. 1/95) S i Minnesota Inspection Number: 303889026 •� y ••.. Department of Labor and Industry Inspection Dates: 12/06/2000 - 12/06/2000 Occupational Safety and Health Division Issuance Date: 01/04/2001 = ' CSHOID: B7736 Optional Inspection Nbr: 01500 } Citation and Notification of Penalty Company Name: Oak Park Heights, City of Inspection Site: 14168 Oak Park Blvd. No., Oak Park Heights, MN 55082-0007 Citation 1 Item 2 Type of Violation: Serious 29 CFR 1910.151(c): Where employees were exposed to injurious corrosive materials, suitable facilities for quick drenching or flushing of the eyes were not provided within the work area for immediate emergency use: No eyewash station was available where Hach SPADNS Reagent for Fluoride with a pH <.5 is dispensed. Abatement Note: An eyewash capable of furnishing fifteen minutes of flushing fluid to the eyes should be made available for emergency use within ten seconds of the hazardous work area. Eyewashes and showers should be located as close as possible to the hazard, and on the same level. The more hazardous the material, the closer in time and distance the unit should be. For strong acids (pH<1) or bases (pH> 12), the unit should be immediately adjacent to the hazard. The eyewash should be designed so that both hands can be free to assist in the irrigation of the eyes. The flushing fluid temperature should be tepid or lukewarm (between 60°F and 95°F) and should not exceed 100°F. The water pressure should not exceed 25 pounds per square inch (PSI). ......::::::>•:F::S::.:....:;:::::::::....:...:::i::;:::':>::;::':�':::r;x::r::..:...:::::::.:::..:;,...:;:.:::+:;::;::::;>::.::>::.::.::.>;:.::;;•:riri:;<•i:,•ii:<;•r:;•riiii:•>i:•:,,;::;.:»»»::..;::•r:.:..:..>....r:....;;..;;.,:•, See pages 1 through 3 of this Citation and Notification of Penalty for information on employer and employee rights and responsibilities. Citation and Notification of Penalty Page 5 of 10 MNOSHD-2(REV. 1/95) • • Minnesota Inspection Number: 303889026 %,Department of Labor and Industry Inspection Dates: 12/06/2000 - 12/06/2000 �°� ' Occupational Safety and Health Division Issuance Date: 01/04/2001 CSHOID: B7736 10 - Optional Inspection Nbr: 01500 Citation and Notification of Penalty Company Name: Oak Park Heights, City of Inspection Site: 14168 Oak Park Blvd. No., Oak Park Heights, MN 55082-0007 Citation 1 Item 3 Type of Violation: Serious 29 CFR 1910.242(b): Compressed air used for cleaning purposes was not reduced to less than 30 p.s.i.: Air-guns used for cleaning purposes in the public works garage / shop were operated at air pressures above 30 p.s.i.. PONVE ........::......... .....::::::::. . . Citation 1 Item 4 Type of Violation: Serious 29 CFR 1910.304(0(4): The path to ground from circuits, equipment, and enclosures was not permanent and continuous: The grounding pin was missing from the three wire cord on the Advance Hydro "wet or dry" vacuum cleaner. See pages 1 through 3 of this Citation and Notification of Penalty for information on employer and employee rights and responsibilities. Citation and Notification of Penalty Page 6 of 10 MNOSHD-2 (REV. 1/95) • • Minnesota Inspection Number: 303889026 Department of Labor and Industry Inspection Dates: 12/06/2000 - 12/06/2000 .•. � °N:':`�'cc"=.. Occupational Safety and Health Division Issuance Date: 01/04/2001 ,y� _. . CSHOID: B7736 Optional Inspection Nbr: 01500 +1 {„ Citation and Notification of Penalty Company Name: Oak Park Heights, City of Inspection Site: 14168 Oak Park Blvd. No., Oak Park Heights, MN 55082-0007 Citation 1 Item 5 Type of Violation: Serious 29 CFR 1910.332(b)(1): Employees were not trained in and familiar with the safetyrelated work practices required by 29 CFR 1910.331 through 29 CFR 1910.335 that pertained to their respective job assignments: Electrical switch on a post by water tower #1 was not in a secured enclosure and was not weatherproof. See pages 1 through 3 of this Citation and Notification of Penalty for information on employer and employee rights and responsibilities. Citation and Notification of Penalty Page 7 of 10 MNOSHD-2(REV. 1/95) • Minnesota Inspection Number: 303889026 ,..•..ti. Department of Labor and Industry Inspection Dates: 12/06/2000 - 12/06/2000 Occupational Safety and Health Division Issuance Date: 01/04/2001 s�7' „r � '?4% CSHO ID: B7736 Optional Inspection Nbr: 01500 4 i85S. . Citation and Notification of Penalty Company Name: Oak Park Heights, City of Inspection Site: 14168 Oak Park Blvd. No., Oak Park Heights, MN 55082-0007 Citation 1 Item 6 Type of Violation: Serious Minn. Rules 5206.0700 subp.2: The employer did not implement Right-to-Know training for employees who were routinely exposed to hazardous substances: The employer has not established RTK training for employees exposed to hazardous substances that would include but not be limited to gasoline,fuel oil, chlorine, fluorosilicic acid, SPANDS reagent for fluoride, insecticides, pesticides and herbicides. Abatement Guidelines: The employer must conduct initial and ongoing evaluations of the workplace to determine the hazardous substances for which there is a reasonable potential for employee exposure during the normal course of assigned work. A written Right-to-Know program must be developed and implemented which describes how the training, availability of information, and labeling requirements will be met. Employees must be provided with training in a manner which can be reasonably understood by them, and which addresses the required topics outlined in 5206.0700, Subpart 2. Training is to be provided at the cost of the employer. Records of training provided under this section must be maintained by the employer and retained for 3 years. The written Right-to-Know program shall include: 1) A description of how the training, availability of information, and labeling provisions will be met for the workplace as a whole or for individual work areas. 2) A list of the hazardous substances known to be present using an identity that is referenced on the appropriate material safety data sheet. A list of frequent tasks that expose employees to physical agents and method the employer will use to inform employees. The list may be compiled for the workplace as a whole or for individual work areas. See pages 1 through 3 of this Citation and Notification of Penalty for information on employer and employee rights and responsibilities. Citation and Notification of Penalty Page 8 of 10 MNOSHD-2(REV. 1/95) • Minnesota Inspection Number: 303889026 ,,,,., '-..,, Department of Labor and Industry Inspection Dates: 12/06/2000 - 12/06/2000 ":05r3lIttt' .,��Occupational Safety and Health Division Issuance Date: 01/04/2001 CSHO ID: B7736 Optional Inspection Nbr: 01500 Citation and Notification of Penalty Company Name: Oak Park Heights, City of Inspection Site: 14168 Oak Park Blvd. No., Oak Park Heights, MN 55082-0007 3) The methods the employer will use to inform employees of the hazards of infrequent tasks that involve exposure to hazardous substances and the hazards associated with hazardous substances contained in unlabeled pipes in their work areas. 4) Additionally, in multiemployer workplaces where the employer produces,uses or stores hazardous substances in such a way that employees of other employers may be exposed, the written Right-to- Know program developed and implemented under Minn. Rules 5206.0700 Subp. 1(b) shall include: a) the methods the employer will use to provide the other employers with a copy of the material safety data sheet, or to make it available at a central location in the workplace, for each hazardous substance the other employers' employees may be exposed to while working; b) the methods the employer will use to inform the other employers on any precautionary measures that need to be taken to protect employees during normal operating conditions and in foreseeable emergencies; and c) the methods the employer will use to inform the other employers of the labeling system used in the workplace. The Right-to-Know training program for hazardous substances shall include: 1) the name or names of the substance including any generic or chemical name, trade name, and commonly used name; 2) the level, if any and if known, at which exposure to the substance has been restricted according to standards adopted by the commissioner, or, if no standard has been adopted, according to guidelines established by competent professional groups which have conducted research to determine the hazardous properties of potentially hazardous substances; 3) the known acute and chronic effects of exposure at hazardous levels, including routes of entry; 4) the known symptoms of the effects; 5) any potential for flammability, explosion, or reactivity of the substance; 6) appropriate emergency treatment; 7) the known proper conditions for use of and exposure to the substance; 8) procedures for cleanup of leaks and spills; 9) the name, phone number, and address of a manufacturer of the hazardous substance; and See pages 1 through 3 of this Citation and Notification of Penalty for information on employer and employee rights and responsibilities. Citation and Notification of Penalty Page 9 of 10 MNOSHD-2(REV. 1/95) • Minnesota Inspection Number: 303889026 Department of Labor and Industry Inspection Dates: 12/06/2000 - 12/06/2000 ���j�7!�1.� OL p Occupational Safety and Health Division Issuance Date: 01/04/200141 CSHO ID: B7736 - • `wla Optional Inspection Nbr: 01500 Citation and Notification of Penalty Company Name: Oak Park Heights, City of Inspection Site: 14168 Oak Park Blvd. No., Oak Park Heights, MN 55082-0007 10) a written copy of all of the above information which shall be readily accessible in the area or areas in which the hazardous substance is used or handled. Records of Right-to-Know training shall include: Records of training must be maintained by the employer for three years, and at a minimum, must include: 1) the dates training was conducted; 2) the name, title, and qualifications of the person who conducted the training; 3) the names and job titles of employees who completed the training; and 4) a brief summary or outline of the information that was included in the training session. The following is the minimum required frequency of training: 1) before the initial assignment to a job where there is a reasonable potential for exposure during the course of assigned work, 2) prior to the time an employee may be exposed to any additional hazardous substance(s), and 3) training updates, to be provided no less than annually. _9!IAIIIRONOXONPNEIKNNIIINRONIEJIMNIIPIIMIIIIMIIIEMDVOEIZOOII t':+:L:i:iiiiiiii$ii$iiii'rii'riii:i:iiii:i:i:ii:?i:i;{:'iii��i ii :Yt:iii?i�iiiiirii'iiii'r 'rr?irii'rii:iii;{:iiiiiit>.vi`':>":�`:�:;::j iii:?<iiiiv iii�'v%i i�ti<• YF " Gretchen B. Maglich Commissioner of the Department of Labor and Industry See pages 1 through 3 of this Citation and Notification of Penalty for information on employer and employee rights and responsibilities. Citation and Notification of Penalty Page 10 of 10 MNOSHD-2(REV. 1/95) • • Minnesota Department of Labor and Industry ,,,, Occupational Safety and Health Division •.,, 443 Lafayette Road St. Paul, MN 55155-4307 '~ '. � 11Y`s`Y Phone: (651)296-2116 FAX: (651) 297-2527 "\tlVq INVOICE Company Name: Oak Park Heights, City of Inspection Site: 14168 Oak Park Blvd. No., Oak Park Heights, MN 55082-2007 Mailing Address: 14168 Oak Park Blvd. No., Oak Park Heights, MN 55082-2007 Issuance Date: 01/04/2001 OSHI ID#: B7736 Optional Report No.: 01500 Summary of Penalties for Inspection Number 303889026 Citation 1, Serious = $ 1875.00 Penalty Payment- Payment of all penalties is to be made by check or money order payable to the order of "Minnesota Department of Labor and Industry" and remitted with a copy of this invoice to the Occupational Safety nd Health Division at the address above within 20 calendar days following receipt of this Citation. After 60 days, unpaid penalties shall increase 25 percent and shall accrue an additional interest of 10 percent per month compounded monthly until the fine is paid in full. If any portion of this Citation and Notification of Penalty is contested, that portion of the penalty is not due and payable until the resolution of the contestation. However, you are still obligated to pay the penalty on the uncontested portion of the citation within 20 calendar days following receipt of this Citation. NOTE: The penalties shown above have already been adjusted for Good Faith, Size and History credits. Page 1 of 1 .072 • Ci of Oak Park Heights 14168 57`h Street N.•Box 2007.Oak Park Heights,MN 55082•Phone(651)4394439•Fax 439-0574 Interoffice Memo To: Mayor and City Council From: Public Works Director, Jay Johnson, PE CC: City Administrator, City Finance Director, MN OSHA Date: 01/12/00 Re: OSHA Citation Status Report The following are citation items and their status. Citation Item: 1-1 Tower# 1 ladder safety. Compliance Date February 1, 2000 The tower ladders were found require additional safety devices. To comply with this requirement DBI SALA LadSaf Ladder Safety Systems are to be installed on all three ladders. This is the same system as used in Tower#2 and therefore will not require additional training in the use of the system. The system consists of a cable supported in the middle of the ladder, a climbing harness and a climbing sleeve. The sleeve attaches to the harness and the cable. The sleeve is designed to free slide up the cable but locks whenever the harness pulls downward against the cable. Status: Three LadSaf systems are on order for delivery on January 19,2000. Installation should be complete by January 23, 2000. Citation Item 1-2 Eyewash station not provided where caustic chemicals are used for fluride analysis. Compliance Date January 18, 2000. Status: Abated January 12, 2000. The eyewash stations were received and placed in service. Citation Item 1-3 Compressed air used for cleaning was not reduced to 30 psi. Compliance Date January 10, 2000 The airgun used for cleaning has a maximum inlet pressure of 150 psi with the outlet pressure reduced to 30 psi maximum nozzle pressure. It also has a non-plugging tip. An older airgun that does not have the pressure reducing device and the non-plugging tip was found in the garage. This older airgun has been plugged with silicon caulk and will be used as an example TREE CITY U.S.A. • of an improper device in safety training programs. Copy of gun is attached showing the pressure rating is attached. A safety procedure (including training) on use of compressed air and compressed fluids will be written and implemented. Status: Abated December 6, 2000 Citation 1-4 Ground plug for wet vac was missing. Compliance Date January 10, 2000 Status: Abated Plug replaced December 8, 2000. December 8, 2000. In addition we have reviewed other power equipment and made repair or removed the items from service as needed. This included two typewriters which needed polarized plugs, a hand drill with frayed wiring (removed from service) and the plug on the compressor. Other electrical safety actions taken include increasing the use of GFI plugs at our park facilities as a continuation of the facility updates started last year. Citation 1-5 Electrical switch on a post by water tower#1 was not in a secured enclosure and was not weatherproof. Compliance Date January 18, 2000. Status: Abated January 11, 2001. The power shutoff switch for the tower has been secured with a padlocked. Linner Electric has filled the opening on the bottom of the box. Pictures attached. According to the electrician from Linner Electric this box meets electrical codes. Based on a review of the original tower drawings,the tower was powered by its own 120 volt electrical feed. Apparently, during one of the modifications which of City Hall the power is now feed through the City Hall electrical system and the is shut-off is redundant. The City Engineer has been asked to review if the switch can be removed all together. Citation 1-6 Employer did not implement Right To Know training for employees exposed to hazardous substances. Compliance Date February 1, 2001. Plan: Hazard Evaluation to be completed by January 17, 2001 Training class prepared and presented by January 25, 2001. Schedule of monthly training sessions completed by January 25, 2001 Record to be kept in Departmental and Personnel files. Status: Hazard evaluation almost complete. Training program design underway. Initial training is scheduled for January 25, 2000. 2 TREE CITY U.S.A. I • '...........; ...._ ., . . . .., # 1.• . „... 11... ' ... , , ,....- i ,„... 77.7. 11, ,..% "..,.- ,..4/ '..: .41 • t 'k . ... li ..., i \ ..... ,. ._. . ,i ! I •-: , :.::,'-'.: I ' - i - - I 1 . 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R''�I w� .fix aka" d lot S £yt f �Ir; 4...' k„t" m a r tea"a.. �:. sit ; I ,... , ""^ssi 'q S xdvi:$a . ; .swF� .,, $'9 u - y x ., . I tTy� � . . ', ,, c:. t i , „ ,„... . , .. .„ , „.... , ..,. .. .. .... ,. . ,., . .. , . wy \\\\�N�1Il�11I111�:I/IIIIII,,,, 0 II • 9T• Minnesota Department of Labor and Industry `D •01.Occupational Safety and Health Division r a 4= ,.. D ;146 OWE ciE -�. 1MM1 9 2001 Subject: CITATION AND NOTIFICATION OF PENALTY for Alleged Occupational Safety and Health Violations and Eligibility for Expedited Informal Settlement Agreement(EISA) A recent inspection of a place of employment under your operation, ownership, or control has resulted in the enclosed Citation and Notification of Penalty which describes alleged violations of the Minnesota Occupational Safety and Health Act of 1973. Please read carefully and follow instructions listed under EMPLOYER AND EMPLOYEE RIGHTS AND RESPONSIBILITIES on . the citation and the following discussion of your eligibility for an EISA. This inspection revealed no instances of Repeated,Willful,or Failure-to Abate violations,nor were there more than two high gravity Serious violations. Additionally, the Occupational Safety and Health Investigator has reported that you have a good understanding of the actions necessary to correct the violations that were cited,and that you are willing tomake those corrections by the dates specified in the Citation and Notification of Penalty. These factors, along with the good faith you have exhibited, make your company eligible for an Expedited Informal Settlement Agreement(EISA). Under this program, an employer can obtain a 30 percent penalty reduction by entering into an informal settlement agreement with MNOSHA, without going through the formal contestation procedure. However,if you decide to enter into an Expedited Informal Settlement Agreement,you should be aware that you waive your right to contest any part of the Citation and Notification of Penalty. You cannot both contest a portion of the Citation and Notification of Penalty and obtain an EISA on the remaining portion. The EISA can be used only where the sole issue of dispute is the dollar amount of the MNOSHA penalty. If you wish to discuss,change, or object to any other aspect of the inspection or citations, then the EISA cannot be used. Under those circumstances, you may file a notice of contest according to the instructions contained on the Citation and Notification of Penalty and the attached Notice of Contest form. • You should carefully read the enclosed EISA to determine whether the terms of the agreement are acceptable to you. Key elements of the agreement include: - MNQSHA agrees to a 30%reduction in the total penalty amount; The employer agrees to post the EISA with the citation; The employer agrees to abate the violations by the date shown in the citations(an employer acting in good faith may request an extension of the original abatement date); The employer agrees to provide evidence of corrective action and submit a written progress report to MNOSHA within 30 days of citation issuance and every-30 days thereafter until all items are abated; The employer agrees to pay the full amount of the reduced penalty at the time that the original signed EISA is returned to MNOSHA. The original signed EISA and payment of reduced penalty(70%of the total original penalty amount)must be received by MNOSHA within 20 calendar days following your receipt of the Citation and Notification of Penalty. Written progress reports must be submitted to MNOSHA to show that you have completed all corrections as of the "date by which the • violation must be abated" shown on the citation. You should be aware that Federal OSHA publishes information on its inspection and citation activity on the Internet under the provisions of the Electronic Freedom of Information Act. The information related to your inspection will be available 30 calendar days after the Citation Issuance Date. You are encouraged to review the information concerning your establishment at WWW.OSHA.GOV. If you have any dispute with the accuracy ofthe information displayed,please • contact this office. If you have any questions regarding the citation or this Expedited Informal Settlement Agreement offer,please contact me at(651) 296-2116. Sincerely, Terry Mueller OMT Director .60 ...... • • �Q�„,ou.enuno ?'t. �/1'�<:47--=~ j Minnesota -_� , _� Department of Labor and Industry •`gip • 1."14-..7:0 -..7: ' ,' Occupational Safety and Health Division In the matter of: Oak Park Heights, City of INSPECTION NO.: 303889026 OSHI ID/OPTIONAL REPORT NO: B7736 015-00 EXPEDITED INFORMAL SETTLEMENT AGREEMENT (Oak Park Heights,City of),by its undersigned representative and Minnesota Occupational Safety and Health Division(MNOSHA) by its undersigned representative, in settlement of the above referenced Citation and Notification of Penalty (CITATION),hereby agree to the disposition of this matter on the following terms: 1. The EMPLOYER agrees to abate the violations as cited, on or before the abatement dates set out in the CITATION. 2. The EMPLOYER agrees to provide evidence of the actions taken to abate the violations by submitting written progress reports to MNOSHA within 30 days of citation issuance and every 30 days thereafter until all items are abated. 3. Upon correction of all violations,the EMPLOYER agrees to post for a period of three days a copy of the final progress report certifying that all violations have been abated in the place where the CITATION is posted. 4. MNOSHA agrees that the total penalty amount is amended to($1,312.00). The EMPLOYER agrees to submit full payment of the amended amount along with this original signed Settlement agreement within 20 days following the EMPLOYER'S receipt of the CITATION. 5. In consideration of the foregoing amendment,the EMPLOYER hereby waives its right to contest the CITATION pursuant to MN Statutes § 182.661. It is understood and agreed by MNOSHA and the EMPLOYER that the CITATION as amended by this agreement shall be deemed a final order of the Commissioner not subject to review by any court or agency. 6. The EMPLOYER agrees to immediately post a copy of this Settlement Agreement in the same manner and place as the CITATION is required to be posted. The signature of the EMPLOYER representative on this Settlement Agreement is understood to be certification of this posting. 7. In addition to action MNOSHA may take against the EMPLOYER pursuant to Minn. Stat. Ch. 182 (1996)and other remedies provided by law,the EMPLOYER agrees that its failure to comply with any term of this agreement shall cause the original penalty amount of($1,875.00) to become due and owing to MNOSHA. • • Expedited Informal Settlement Agreement Page 2 • 8. Each party hereby agrees to bear its own fees and other expenses incurred with this proceeding and the EMPLOYER further agrees to waive all claims it may have, now and in the future, under MN Statutes §15.472 for fees and expenses arising out of this case. 46, v EMPLOYER Representative MNOSHA 'epresentative OMT Director Title Title 1 . 11101 Date Signed Date Signed NOTICE TO EMPLOYEES Any employee or authorized employee representative who has an objection to the above referenced Citation and Notification of Penalty may contest the citation within 20 calendar days of the employer's receipt of it, in accordance with the instructions on page 3 of the Citation and Notification of Penalty. In addition, any employee or authorized employee representative who has an objection to the Citation and Notification of Penalty as amended by this agreement may contest the amended citation within 20 calendar days of the posting of this Settlement Agreement. COMPLETE Aril RETURN THIS FORM WS-IIN 30 DAYS osha MANDATORY PROGRESS REPORT DEPAITVailofLAM 1.4:)hiASai • Return to: Minnesota OSH Division For Office Use Only 443 Lafayette Road oComplete St. Paul, Minnesota 55155 ❑Incomplete ❑Extension Request Phone: (651) 296-2116 FAX: (651) 297-2527 In accordance with MN Rule 5210.0532,this report MUST be returned to the Area Office designated above. Failure to submit all require, progress reports will result in an additional citation, penalty, and/or followup inspection.The completed Progress Report Form is to be mailed by the latest abatement date on the citation, or within 30 days after receipt of the citation, whichever is earlier. Additional reports (if necessary) are to be sent at 30 day intervals until all items have been fully abated. From: THOMAS MELENA Inspection No. OAK PARK HEIGHTS, CITY OF 14168 OAK PARK BLVD N Optional Report No. Jobsite: OAK PARK HEIGHTS MN OSHI ID 55082-2007 87736 015-00 303889026 (GI) FILL IN ONE Citation a Abatement Date Abated Anticipated and Item Action Taken - Date on (Corrected) Completion Date No. Citation (See Note) NOTE: If the anticipated completion date is beyond the date by which the alleged violation must be abated,you must submit a separat, written Petition for Modification of Abatement Date (PMA)to request an extension of time allowed for completion. See the instructioi for a PMA on page 2 of the Citation and Notification of Penalty. A copy of this Progress Report must be posted for 15 days where the citation and notification of penalty is posted and all affect. employees and their representatives must be informed of their right to examine and copy all abatement documents submitted to t Commissioner. I hereby certify that this information is accurate. Completed by: Title: Telephone: Date: (Revised 4/98) EXAMPLE ON BACK 6 COMPLETE AND RETURN THIS FORM WITHIN 30 DAYS osha MANDATORY PROGRESS REPORT pfnikfl.iEXT OF LA:K12 MD MDUSTY Return to: Minnesota OSH Division For Office Use Only ? 3T=aiayette Road ❑Complete St. Paul, Minnesota 55155 ❑Incomplete ❑Extension Request Telephone: 651/296-2116 Fax: 651/297-2527 In accordance with MN Ru ;;. 21 7532, this report MUST be returned to the Area Office designated above. Failure to submit all required progress reports wi .:.. It in an additional citation, penalty, and/or followup inspection. The completed Progress Report Form is to be mailed by th9 st abatement date on the citation, or within 30 days after receipt of the citation, whichever is earlier. Additional reports,(tfrna:c„ sary) are to be sent at 30 day intervals until all items have been fully abated. From: Company Name `� Company Address Inspection No. 300000000 City, State Zip OSHI ID: S9999 • Optional Report No. 001-98 Jobsite: : FILL IN ONE Citation Action aken Abatement Date Anticipated and Item Date on Abated Completion Date No. Citation (Corrected) (See Note) 1-1 Safety goggle eye protection has been provided to workers in 7/10 7/6 washer area. : 1-2 Fan removed from site; no longer available ::r us iiii 7/10 7/3 1-3 Shower/eyewash station installed 8/10 8/2 2-1 Right-to-Know program written 7/21 7/17 a. MSDSs consolidated; missing MSDSs requested from mfrs 8/10 9/1 b. training program updated and being conducted by departm8/10 9/1 c. training records updated; maintenance system established:;' 7/21 7/17 d. training will be conducted for all new employees upon hire= P :::» 7/21 7/17 gi 2-2 Respirator removed from work area and no longer available for use; 7/21 7/3 written respirator program no longer required. NOTE: If the anticipated completion date is beyond the date by which the alleged violation must be abated,you must submit a separate written Petition for Modification of Abatement Date (PMA) to request an extension of time allowed for completion. See instructions for a PMA on page 2 of the Citation and Notification of Penalty. A copy of this Progress Report must be posted for 15 days where the citation and notific'.'`ion of penalty is posted and all affected employees and their representatives must be informed of their right to examine and co all abatement documents submitted to the Commissioner. ( hereby certify that this information is accurate. Completed by: Title: • Telephone: Date: ` ~ ”1 (Revised 4/98) , — Minnesota Inspection Number: S Department of Labor and In*try OSHI ID: Optional Report No.: Occupational Safety and Health Division 443 Lafayette Road Employer's Name and Mailing Address St. Paul, MN 55155-4307 Phone: (651) 296-2116 FAX: (651) 297-2527 NOTICE OF CONTEST AND SERVICE TO AFFECTED EMPLOYEES PURPOSE OF THIS FORD This Notice of Contest and Service to Affected Employees form (Notice of Contest form) should ONLY be completed by an employer who has received a Citation and Notification of Penalty from the Minnesota Occupational Safety and Health Division (MNOSHA), who wishes to contest that a violation occurred, the type of violation, the proposed penalty and/or the date by which the violation must be abated. If the employer only wishes to obtain an extension of time to abate the violation, the employer may file a Petition for Modification of Abatement Date according to the instructions on the Citation and Notification of Penalty. By filing this Notice of Contest form, the employer is initiating a formal contested case proceeding before an administrative law judge of the parts of the Citation and Notification of Penalty it is contesting. This form must be filed in good faith and not solely for delay or avoidance of penalties. Upon receipt of a timely-filed Notice of Contest form, MNOSHA will contact the employer and schedule a date, time and location for an informal conference. The purpose of the informal conference is to allow the employer to discuss with a MNOSHA representative the Citation and Notification of Penalty and the basis for the employer's contest. The goal of the informal conference is to reach an early informal resolution of the contest. If the employer and MNOSHA are unable to reach a resolution at the informal conference then the contest will proceed to a formal contested case hearing.' FILING THIS FORM This Notice of Contest form must be filed with the Commissioner of the Department of Labor and Industry at the above address within 20 days after the date the Citation and Notification of Penalty is received by the employer. To be considered filed, all parts of the Notice of Contest form must be completed and the completed form must be deposited in the United States mail and postmarked, or otherwise timely received by the Commissioner at the above address within 20 days after the date the Citation and Notification of Penalty is received by the employer. Facsimile (FAX) transmittal of this form is acceptable, followed by receipt of the mailed original within 5 days. If the employer fails to file the Notice of Contest form on time, the Citation becomes a final order of the Commissioner which is not subject to review by any court or agency. COMPLETING THIS FORM 1. HOW TO IDENTIFY THE INSPECTION BEING CONTESTED. The employer must complete the box at the top of page 1 of this form using the Inspection Number, OSHI ID, Optional Report Number and Employer's Mailing Address from the Citation and Notification of Penalty being contested. 2. HOW TO POST AND SERVE THIS FORM. The employer must post a fully completed copy of both pages of this form where the contested Citation and Notification of Penalty is posted no later than the last day this form may be filed. The form must remain posted until the date of the formal contested case hearing or earlier final resolution of the contest. If there are any affected employees who are represented by an authorized employee representative, the employer shall, on or before the date this form is required to be filed with the Commissioner, serve a fully completed copy of the form upon the representative. Service may be accomplished by either postage prepaid first class mail or personal delivery. (Revised 8/97) 3. DATE OF POSTING. The employe st certify in Box A or B below the dates which it posted and served this form. Employers who have affected Employees A. Employers who have-affected Employees B. IVot: Represented By Authorized Employee Represented by Anthonzed Employee • Representatives (union) Representatives. I hereby certify that I posted fully completed copies I hereby certify that I posted fully completed copies of this form on / / (date) of this form on / / (date) at the locations where the Citation and Notification at the locations where the Citation and Notification of Penalty is posted; and I served fully completed of Penalty is posted and that I do not have any copies of this form on / / (date) affected employees who are represented by upon the authorized employee representatives of authorized employee representatives. affected employees. 4. HOW'TO CONTEST THE CITATION AND NOTIFICATION OF PENALTY. The employer must indicate in the boxes below which part of the Citation and Notification of Penalty it wishes to contest. First the employer must identify the citations it is contesting by indicating the citation and item numbers. (For example, "Citation 1, Item 2"). Then the employer must indicate which parts of each item is being contested. Finally, the employer must state the reasons for contesting in the space provided below the boxes. • Check the box under the heading CITATION, if the employer wishes to contest that the violation occurred. • Check the box under the heading TYPE OF VIOLATION, if the employer wishes to contest the characterization of the violation as non-serious, serious, willful or repeat. • Check the box under the heading ABATEMENT DATE, if the employer wishes to contest the date by which you must abate the violation. • Check the box under the heading PENALTY, if the employer wishes to contest the amount of the penalty. FAILURE°TO CHECK ANY PART WILL RESULT IN THAT PART OF THE CITATION BECOMING A FINAL ORDER OF THE COMMISSIONER WHICH IS NOT.REVIEWABLE BY ANY COURT OR AGENCY. CITATION CITATION • TYPE OF ABATEMENT • PENALTY. NUMBER • VIOLATION <•DATE AND; u1M NUMBER I contest that a I contest the I contest the I contest the Violation occurred Type of Violation Abatement Date Amount of the Penalty • REASONS FOR CONTEST: (additional sheets may be attached as necessary) 5. OATH The employer completing this form must sign and have notarized the following statement. I SWEAR THAT THE INFORMATION PROVIDED ON THIS FORM AND ATTACHED TO THIS FORM IS ACCURATE AND TRUTHFUL TO THE BEST OF MY KNOWLEDGE. Subscribed and sworn to before me this date of , 19_ Name of Employer Representative Title Notary Public ) Phone My Commission expires ,19_ Signature Date • Minnesota Department of Labor and Industry % Occupational Safety and Health Division 443 Lafayette Road St. Paul, MN 55155-4307 tia Phone: (651)296-2116 FAX: (651) 297-2527 .; + ��'^ ;' Citation and Notification of Penalty .......... To: Inspection Number: 303889026 Oak Park Heights, City of OSHI ID: 14168 Oak Park Blvd. No. B7736 Optional Report No.: 01500 Oak Park Heights, MN 55082-2007 Inspection Date(s): 12/06/2000 - 12/06/2000 Inspection Site: Issuance Date: 01/04/2001 14168 Oak Park Blvd. No. The violation(s)described in this Citation a nd iVotiication Oak Park Heights, MN 55082-2007 ' of Penalty is (are)alleged to have occurred ori ar about the day(s) the inspection was made`unlessiotherwise.indicated within the description given below This Citation and Notification of Penalty (this Citation) describes violations of the Minnesota Occupational Safety and Health Act of 1973 (the Act). The penalty amounts listed herein are based on these violations. You must abate the violations referred to in this Citation by the dates listed and pay the penalties, unless within 20 calendar days from your receipt of this Citation you file a Notice of Contest with the Commissioner of the Department of Labor and Industry. Your contestation rights and other employer and employee rights and responsibilities are set out in the first three pages of this Citation. The description of alleged violations begins on page 4 of this Citation. EMPLOYER AND EMPLOYEE RIGHTS AND RESPONSIBILITIES Posting - The Act requires that a copy of this Citation shall be promptly posted at or near each place that an alleged violation referred to in the citation occurred. If uncontested, this Citation must remain posted until all alleged violations cited therein are corrected, or for 20 days, whichever is longer. If contested, this Citation must remain posted until the contestation is resolved. Penalty Payment- Payment of all penalties is to be made by check or money order payable to "Minnesota Department of Labor and Industry" and remitted to the Occupational Safety and Health Division at the address above within 20 calendar days following receipt of this Citation. After 60 days, unpaid penalties shall increase 25 percent and shall accrue an additional interest of 10 percent per month compounded monthly until the fine is paid in full. Citation and Notification of Penalty Page 1 of 10 MNOSHD-2 (Rev. 1/95) • • Notification of Corrective Action - Progress reports on correction of alleged violations not immediately abated shall be submitted on the Progress Report form provided with this Citation. Written progress reports must be submitted to the Area Office indicated in the cover letter accompanying this Citation within 30 calendar days of the issuance date. Reports must state the specific corrective action taken on each cited item, the date of such action and the anticipated abatement date of uncompleted items. Additional written progress reports shall be submitted every thirty days until the items are fully abated. Facsimile (FAX) transmittal is acceptable. All alleged violations not contested must be corrected by the abatement date specified in this Citation. A followup inspection may be made for the purpose of ascertaining that the employer has corrected the alleged violations and posted this Citation as required by the Act. Failure to correct an alleged violation by the abatement date on this Citation may result in further penalties for each day the alleged violation has not been corrected. Petition for Modification of Abatement Date (PMA) - If, due to factors beyond reasonable control, compliance cannot be achieved by the abatement day on the citation, the employer may file a Petition for Modification of Abatement Date (PMA) to obtain an extension of the abatement time period. The PMA must be in writing and received by the Area Office at the address indicated in the cover letter prior to the expiration of the abatement date on the citation. Facsimile (FAX) transmittal of a PMA is acceptable. A copy of the PMA must be posted for ten days in the location where this Citation is posted. A copy of the PMA must also be served upon authorized employee representatives. The employer's written petition must describe: 1) The action that has been taken so far to achieve compliance; 2) The amount of additional time needed for compliance; 3) The reasons why additional time is needed; 4) A description of the interim steps that will be taken to safeguard employees against the cited hazard; 5) A statement that employees have been notified of the PMA filing. Employees have the right to file a written objection to the Commissioner regarding the employer's PMA request. A copy of the objection must be served on the employer within 10 days of the employer's posting of the PMA. The employee objection must be received by the Commissioner within 15 days of the employer's PMA request. Facsimile (FAX) transmittal is acceptable. Employer Right to Contest - The employer has the right to a hearing to contest any or all parts of this Citation. If the employer wishes to contest, the employer must fully complete and notarize the attached NOTICE OF CONTEST AND SERVICE TO AFFECTED EMPLOYEES (Notice of Contest form) and file it with the Commissioner at the address shown on page 1 of this Citation within 20 calendar days of receiving the citation. Important: To be considered filed, all parts of the Notice of Contest form must be completed and the completed form must be deposited in the United States mail and postmarked, or otherwise timely received by the Commissioner at the above address within 20 days after the date this Citation is received by the employer. Facsimile (FAX) transmittal is acceptable, followed by the mailed ori employer fails to file the Notice of Contest form on time, this Citation and Notification ofwitfP Pena5 lty �o thes a final order of the Commissioner which is not subject to review by any court or agency and the Occupational Citation and Notification of Penalty Page 2 of 10 MNOSHD-2 (Rev. 1/95) • Safety and Health Division may file and enforce the penalty as a district court judgment without further notice or additional proceedings pursuant to Minnesota Statutes 16D.17. Employee Right to Contest - An employee or authorized representative of employees has the right to a hearing to contest this Citation by filing a letter with the Commissioner of the Department of Labor and Industry at the address shown on page 1 within 20 calendar days of the employer's receipt of this Citation. Important: To be considered filed, an employee letter of contest must be depostied in the United States mail and postmarked, or otherwise timely received by the Commissioner at the above address within 20 days after the date this Citation is received by the employer. Facsimile mailed original within 5 days. If the employee fails to file letter trof contest on mittal is acceptable, ime, this Citation yand Notification of Penalty becomes a final order of the Commissioner which is not subject to review by any court or agency and the Occupational Safety and Health Division may file and enforce the penalty as a district court judgment without further notice or additional proceedings pursuant to Minnesota Statutes 16D.17. Employee Right to Party Status - Affected employees or their authorized employee representatives may elect to participate as parties in the formal contested case hearing before the start of the hearing by filing written notice with the Commissioner at the address shown above. The notice must contain the employees' names, addresses, authorized employee representatives, if any, and a statement that they are affected employees of the cited employer. Employer Discrimination Unlawful-Employees who believe that they have been discharged or otherwise discriminated against by any person because the employees have exercised any right authorized under the provisions of Minnesota Statute§ 182.674, may, within 30 days after such alleged discrimination occurs, file a complaint with the Commissioner of the Department of Labor and Industry at the address shown above, alleging the discriminatory act. Citation and Notification of Penalty Page 3 of 10 MNOSHD-2 (Rev. 1/95) • • Minnesota Inspection Number: 303889026 Department of Labor and Industry Inspection Dates: 12/06/2000 - 12/06/2000 °,10 Occupational Safety and Health Division ��■D� ;• Issuance Date: 01/04/2001 • !�' `'�''15;111 CSHOID: B7736 � v Optional Inspection Nbr: 01500 Citation and Notification of Penalty Company Name: Oak Park Heights, City of Inspection Site: 14168 Oak Park Blvd. No., Oak Park Heights, MN 55082-0007 Citation 1 Item 1 Type of Violation: Serious 29 CFR 1910.27(d)(2): Fixed ladder(s)used to ascend to heights exceeding 20 feet, and where cages or wells were not provided, were not provided with a landing platform for each 20 feet of height or fraction thereof: Employees ascend and descend fixed ladders inside water tower#1 which extend 24 ft., 76 ft. and 35 ft. vertically and do not contain the required number of landing platforms or any other related ladder safety devices.reettIMMOMONEWANNOMENIEMEIMI q �i:ii;::•i:{•}iiii::iij::yi:?:ry:•i}iii:::.::........ ..Y.v:•?:::v::.:;•::::::.........:::::::::.......P ..: i...WkikT •... .r ........................... ..... :.:::::::........... ..:........ w.�.:�:{{moi.............., :{.::: ::.•'.:�•:•':�::::::::::{•y.�:.�:::iiiii'.:4ii?i;Gi;•i}i'r;:i'ii:{.?:{{{{{J::i:•}>•::::::::::::}•:::.�::::::::::}i'.:�::::::::{4;::::::•::::::::ii:::•:::::::::::i}:{{;}:::::::::::•:: .................:::::.�.�::::::::ii}i:{{•iy;;.i::::iiii::.ii:.ii':.�::{G:{{?i}iii::.�:.�:::n;{{•ii•._i:{•ii:Li:J:4i:{::::{•iiii:{:P;{:.�::::::::::i}}?:::::::::::::xi;•:•:::::.v::::nom:::.• ....\. .................::.�:::::::::.::i:^iii:{4i:{Pi:{{^};i:i::}:i:i}Y:i:iii ijr w::.::.�.m;\•:+;::G'i::i::iix:;};,.;.iv:i:•: S i;•iii:•iii:Lii:•:{{•i.�.�:{:{:..:::....r....rr. • See pages 1 through 3 of this Citation and Notification of Penalty for information on employer and employee rights and responsibilities. Citation and Notification of Penalty Page 4 of 10 MNOSHD-2(REV. 1/95) • 0 Minnesota Inspection Number: 303889026 Department of Labor and Industry Inspection Dates: 12/06/2000 , Occupational Safety12/06/2000 ��$� p and Health Division Issuance Date: 01/04/2001 �N;, CSHO ID: B7736 _ vQr _ Optional Inspection Nbr: 01500 1� - -- S Citation and Notification of Penalty Company Name: Oak Park Heights, City of Inspection Site: 14168 Oak Park Blvd. No., Oak Park Heights, MN 55082-0007 Citation 1 Item 2 Type of Violation: Serious 29 CFR 1910.151(c): Where employees were exposed to injurious corrosive materials, suitable facilities for quick drenching or flushing of the eyes were not provided within the work area for immediate emergency use: No eyewash station was available where Hach SPADNS Reagent for Fluoride with a pH <.5 is dispensed. Abatement Note: An eyewash capable of furnishing fifteen minutes of flushing fluid to the eyes should be made available for emergency use within ten seconds of the hazardous work area. Eyewashes and showers should be located as close as possible to the hazard, and on the same level. The more hazardous the material, the closer in time and-distance the unit should be. For strong acids (pH<1) or bases (pH>12), the unit should be immediately adjacent to the hazard. The eyewash should be designed so that both hands can be free to assist in the irrigation of the eyes. The flushing fluid temperature should be tepid or lukewarm (between 60°F and 95°F) and should not exceed 100°F. The water pressure should not exceed 25 pounds per square inch (PSI). See pages 1 through 3 of this Citation and Notification of Penalty for information on employer and employee rights and responsibilities. Citation and Notification of Penalty Page 5 of 10 MNOSHD-2 (REV. 1/95) • • Minnesota Inspection Number: 303889026 Department of Labor and Industry Inspection Dates: 12/06/2000 e%., - 12/06/2000 Occupational Safety and Health DivisionIssuance Date: ` '.2's 01/04/2001 n CSHO ID: B7736 �` �,; ' Optional Inspection Nbr: 01500 ,�•. , di 18. Citation and Notification of Penalty Company Name: Oak Park Heights, City of Inspection Site: 14168 Oak Park Blvd. No., Oak Park Heights, MN 55082-0007 Citation 1 Item 3 Type of Violation: Serious 29 CFR 1910.242(b): Compressed air used for cleaning purposes was not reduced to less than 30 p.s.i.: Air-guns used for cleaning purposes in the public works garage / shop were operated at air pressures above 30 p.s.i.. PNIMERROMMINAIWKINIMMENIIIIIIIIIMMOI Citation 1 Item 4 Type of Violation: Serious 29 CFR 1910.304(0(4): The path to ground from circuits, equipment, and enclosures was not permanent and continuous: The grounding pin was missing from the three wire cord on the Advance Hydro "wet or dry" vacuum cleaner. :VaittiiiiiiiiiiiiiiiiiiiiiiiiiiiiiingingilliiiiiiMMINIUMENO See pages 1 through 3 of this Citation and Notification of Penalty for information on employer and employee rights and responsibilities. Citation and Notification of Penalty Page 6 of 10 MNOSHD-2 (REV. 1/95) • Minnesota Inspection Number: 303889026 Department of Labor and Industry Inspection Dates: 12/06/2000 .''..:•• Occupational Safetyand Health Division - 12/06/2000 �Y. _.,, Issuance Date: 01/04/2001 �r�..`�'-;,,,, , ��_`��`: CSHOID: B7736 : v, Optional Inspection Nbr: 01500 -" ��� -- *j8;. Citation and Notification of Penalty Company Name: Oak Park Heights, City of Inspection Site: 14168 Oak Park Blvd. No., Oak Park Heights, MN 55082-0007 Citation 1 Item 5 Type of Violation: Serious 29 CFR 1910.332(b)(1): Employees were not trained in and familiar with the safetyrelated work practices required by 29 CFR 1910.331 through 29 CFR 1910.335 that pertained to their respective job assignments: Electrical switch on a post by water tower #1 was not in a secured enclosure and was not weatherproof. 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See pages 1 through 3 of this Citation and Notification of Penalty for information on employer and employee rights and responsibilities. Citation and Notification of Penalty Page 7 of 10 MNOSHD-2(REV. 1/95) • • Minnesota Inspection Number: 303889026 Department of Laborand Industry Inspection D 12/06/2 eP Ins cti Dates: 000 12/06/2000 ��''�''•� •""''• Occupational Safety and Health Division `/. U"' " Issuance Date: 01/04/2001 `t ��'�= N CSHO ID: B7736 '�` i([ Optional Inspection Nbr: 01500 \--, -- Citation and Notification of Penalty '�'L Company Name: Oak Park Heights, City of Inspection Site: 14168 Oak Park Blvd. No., Oak Park Heights, MN 55082-0007 Citation 1 Item 6 Type of Violation: Serious Minn. Rules 5206.0700 subp.2: The employer did not implement Right-to-Know training for employees who were routinely exposed to hazardous substances: The employer has not established RTK training for employees exposed to hazardous substances that would include but not be limited to gasoline,fuel oil, chlorine, fluorosilicic acid, SPANDS reagent for fluoride, insecticides, pesticides and herbicides. Abatement Guidelines: The employer must conduct initial and ongoing evaluations of the workplace to determine the hazardous substances for which there is a reasonable potential for employee exposure during the normal course of assigned work. A written Right-to-Know program must be developed and implemented which describes how the training, availability of information, and labeling requirements will be met. Employees must be provided with training in a manner which can be reasonably understood by them, and which addresses the required topics outlined in 5206.0700, Subpart 2. Training is to be provided at the cost of the employer. Records of training provided under this section must be maintained by the employer and retained for 3 years. The written Right-to-Know program shall include: 1) A description of how the training, availability of information, and labeling provisions will be met for the workplace as a whole or for individual work areas. 2) A list of the hazardous substances known to be present using an identity that is referenced on the appropriate material safety data sheet. A list of frequent tasks that expose employees to physical agents and method the employer will use to inform employees. The list may be compiled for the workplace as a whole or for individual work areas. See pages 1 through 3 of this Citation and Notification of Penalty for information on employer and employee rights and responsibilities. Citation and Notification of Penalty Page 8 of 10 MNOSHD-2(REV. 1/95) M • Minnesota Inspection Number: 303889026 Department of Labor and Industry Inspection Dates: 12/06/2000 12/06/2000 '' DpQ••,.,',,• •�OlL6 DS1 Occupational Safety and Health Division Issuance Date: 01/04/2001 Nr_ , CSHO ID: B7736 70.11"*" `• Optional Inspection Nbr: 01500 Citation and Notification of Penalty Company Name: Oak Park Heights, City of Inspection Site: 14168 Oak Park Blvd. No., Oak Park Heights, MN 55082-0007 3) The methods the employer will use to inform employees of the hazards of infrequent tasks that involve exposure to hazardous substances and the hazards associated with hazardous substances contained in unlabeled pipes in their work areas. 4) Additionally, in multiemployer workplaces where the employer produces, uses or stores hazardous substances in such a way that employees of other employers may be exposed, the written Right-to- Know program developed and implemented under Minn. Rules 5206.0700 Subp. 1(b) shall include: a) the methods the employer will use to provide the other employers with a copy of the material safety data sheet, or to make it available at a central location in the workplace, for each hazardous substance the other employers' employees may be exposed to while working; b) the methods the employer will use to inform the other employers on any precautionary measures that need to be taken to protect employees during normal operating conditions and in foreseeable emergencies; and c) the methods the employer will use to inform the other employers of the labeling system used in the workplace. The Right-to-Know training program for hazardous substances shall include: 1) the name or names of the substance including any generic or chemical name, trade name, and commonly used name; 2) the level, if any and if known, at which exposure to the substance has been restricted according to standards adopted by the commissioner, or, if no standard has been adopted, according to guidelines established by competent professional groups which have conducted research to determine the hazardous properties of potentially hazardous substances; 3) the known acute and chronic effects of exposure at hazardous levels, including routes of entry; 4) the known symptoms of the effects; 5) any potential for flammability, explosion, or reactivity of the substance; 6) appropriate emergency treatment; 7) the known proper conditions for use of and exposure to the substance; 8) procedures for cleanup of leaks and spills; 9) the name, phone number, and address of a manufacturer of the hazardous substance; and See pages 1 through 3 of this Citation and Notification of Penalty for information on employer and employee rights and responsibilities. Citation and Notification of Penalty Page 9 of 10 MNOSHD-2(REV. 1/95) S Minnesota Inspection Number: 303889026 '' Department of Labor and Industry Inspection Dates: 12/06/2000 - 12/06/2000 " Occupational �' '`� Safety and Health Division Issuance Date: 01/04/2001 CSHOID: B7736 _`: Optional Inspection Nbr: 01500 !1 }. Citation and Notification of Penalty Company Name: Oak Park Heights, City of Inspection Site: 14168 Oak Park Blvd. No., Oak Park Heights, MN 55082-0007 10) a written copy of all of the above information which shall be readily accessible in the area or areas in which the hazardous substance is used or handled. Records of Right-to-Know training shall include: Records of training must be maintained by the employer for three years, and at a minimum, must include: 1) the dates training was conducted; 2) the name, title, and qualifications of the person who conducted the training; 3) the names and job titles of employees who completed the training; and 4) a brief summary or outline of the information that was included in the training session. The following is the minimum required frequency of training: 1) before the initial assignment to a job where ibere is a reasonable potential for exposure during the course of assigned work, 2) prior to the time an employee may be exposed to any additional hazardous substance(s), and 3) training updates, to be provided no less than annually. NwitringsmaimmiNimmignommmigmonimimemmommoViming CCOO .........:.................. Gretchen B. Maglich Commissioner of the Department of Labor and Industry See pages 1 through 3 of this Citation and Notification of Penalty for information on employer and employee rights and responsibilities. Citation and Notification of Penalty Page 10 of 10 MNOSHD-2(REV. 1/95) • S Minnesota Department of Labor and Industry Occupational Safety and Health Division ..•° ;' s` 443 Lafayette Road ;7?.*:411:; �c�St. Paul, MN 5515 5-4307 ' - . s.711* n% Phone: (651)296-2116 FAX: (651) 297-2527 INVOICE Company Name: Oak Park Heights, City of Inspection Site: 14168 Oak Park Blvd. No., Oak Park Heights, MN 55082-2007 Mailing Address: 14168 Oak Park Blvd. No., Oak Park Heights, MN 55082-2007 Issuance Date: 01/04/2001 OSBI ID#: B7736 Optional Report No.: 01500 Summary of Penalties for Inspection Number 303889026 Citation 1, Serious = $ 1875.00 Penalty Payment- Payment of all penalties is to be made by check or money order payable to the order of Minnesota Department of Labor and Industry" and remitted with a copy of this invoice to the Occupational Safety and Health Division at the address above within 20 calendar days following receipt of this Citation. After 60 days, unpaid penalties shall increase 25 percent and shall accrue an additional interest of 10 percent per month compounded monthly until the fine is paid in full. • If any portion of this Citation and Notification of Penalty is contested, that portion of the penalty is not due and payable until the resolution of the contestation. However, .you are still obligated to pay the penalty on the uncontested portion of the citation within 20 calendar days following receipt of this Citation. NOTE: The penalties shown above have already been adjusted for Good Faith, Size and History credits. Page 1 of 1 .._ _. I2L010.1e.DQ..e-Tc•P jer,S- L3 g"S 10/0( 11)(Lk CA 1-11S% VN•• ••• - ta i•X-C A if. 0 ‘14 2 /1 /(21 V. -k-ktLurc V-2> _ • _ _ _ . . _ ,••°vO `pILEDU y 9T • Minnesota Department of abor and •;�� DRo - p Industry �.�. Occupational Safety and Health Division " CCC OMC 11 E 9 2M j ,,,•I,'''•••`L' 1858• .1'°'G°' Subject: CITATION AND NOTIFICATION OF PENALTY for Alleged Occupational Safety and Health Violations and Eligibility for Expedited Informal Settlement Agreement (EISA) A recent inspection of a place of employment under your operation, ownership, or control has resulted in the enclosed Citation and Notification of Penalty which describes alleged violations of the Minnesota Occupational Safety and Health Act of 1973. Please read carefully and follow instructions listed under EMPLOYER AND EMPLOYEE RIGHTS AND RESPONSIBILITIES on the citation and the following discussion of your eligibility for an EISA. This inspection revealed no instances of Repeated,Willful,or Failure-to Abate violations,nor were there'more than two high gravity Serious violations. Additionally, the Occupational Safety and Health Investigator has reported that you have a good understanding of the actions necessary to correct the violations that were cited,and that you are willing to make those corrections by the dates specified in the Citation and Notification of Penalty. -- These factors, along with the good faith you have exhibited, make your company eligible for an Expedited Informal Settlement Agreement(EISA). Under this program, an employer can obtain a 30 percent penalty reduction by entering into an informal settlement agreement with MNOSHA, without going through the formal contestation procedure. However,if you decide to enter into an Expedited Informal Settlement Agreement,you should be aware that you waive your right to contest any part of the Citation and Notification of Penalty. You cannot both contest a portion of the Citation and Notification of Penalty and obtain an EISA on the remaining portion. The EISA can be used only where the sole issue of dispute is the dollar amount of the MNOSHA penalty. If you wish to discuss, change,or object to any other aspect of the inspection or citations, then the EISA cannot be used. Under those circumstances, you may file a notice of contest according to the instructions contained on the Citation and Notification of Penalty and the attached Notice of Contest form. • You should carefully read the enclosed EISA to determine whether the terms of the agreement are acceptable to you. Key elements of the agreement include: - MNQS.HA agrees to a 30%reduction in the total penalty amount; - The employer agrees to post the EISA with the citation; The employer agrees to abate the violations by the date shown in the citations(an employer acting in good faith may request an extension of the original abatement date); - The employer agrees to provide evidence of corrective action and submit a written progress report to MNOSHA within 30 days of citation issuance and every-30 days thereafter until all items are abated; The employer agrees to pay the full amount of the reduced penalty at the time that the original signed EISA is returned to MNOSHA. The original signed EISA and payment of reduced penalty(70% of the total original penalty amount)must be received by MNOSHA within 20 calendar days following your receipt of the Citation and Notification of Penalty. Written progress reports must be submitted to MNOSHA to show that you have completed all corrections as of the "date by which the violation must be abated" shown on the citation. You should be aware that Federal OSHA publishes information on its inspection and citation activity on the Internet under the provisions of the Electronic Freedom of Information Act. The information related to your inspection will be available 30 calendar days after the Citation Issuance Date. You are encouraged to review the information concerning your establishment at WWW.OSHA.GOV. If you have any dispute with the accuracy ofthe information displayed,please • contact this office. If you have any questions regarding the citation or this Expedited Informal Settlement Agreement offer,please contact me at(651)296-2116. Sincerely, Terry Mueller OMT Director • • • 46 �t� �: _ Minnesota ` ;�� = Department of Labor and Industry stry .....4... ��•4 'x:18 :;r a, Occupational Safety and Health Division In the matter of: Oak Park Heights, City of INSPECTION NO.: 303889026 OSHI ID/OPTIONAL REPORT NO: B7736 015-00 EXPEDITED INFORMAL SETTLEMENT AGREEMENT (Oak Park Heights,City of),by its undersigned representative and Minnesota Occupational Safety and Health Division (MNOSHA) by its undersigned representative, in settlement of the above referenced Citation and Notification of Penalty(CITATION),hereby agree to the disposition of this matter on the following terms: 1. The EMPLOYER agrees to abate the violations as cited, on or before the abatement dates set out in the CITATION. 2. The EMPLOYER agrees to provide evidence of the actions taken to abate the violations by submitting written progress reports to MNOSHA within 30 days of citation issuance and every 30 days thereafter until all items are abated. 3. Upon correction of all violations,the EMPLOYER agrees to post for a period of three days a copy of the final progress report certifying that all violations have been abated in the place where the CITATION is posted. 4. MNOSHA agrees that the total penalty amount is amended to($1,312.00). The EMPLOYER agrees to submit full payment of the amended amount along with this original signed Settlement agreement within 20 days following the EMPLOYER'S receipt of the CITATION. 5. In consideration of the foregoing amendment,the EMPLOYER hereby waives its right to contest the CITATION pursuant to MN Statutes § 182.661. It is understood and agreed by MNOSHA and the EMPLOYER that the CITATION as amended by this agreement shall be deemed a final order of the Commissioner not subject to review by any court or agency. 6. The EMPLOYER agrees to immediately post a copy of this Settlement Agreement in the same manner and place as the CITATION is required to be posted. The signature of the EMPLOYER representative on this Settlement Agreement is understood to be certification of this posting. 7. In addition to action MNOSHA may take against the EMPLOYER pursuant to Minn. Stat. Ch. 182 (1996)and other remedies provided by law,the EMPLOYER agrees that its failure to comply with any term of this agreement shall cause the original penalty amount of($1,875.00) to become due and owing to MNOSHA. • • Expedited Informal Settlement Agreement Page 2 • 8. Each party hereby agrees to bear its own fees and other expenses incurred with this proceeding and the EMPLOYER further agrees to waive all claims it may have, now and in the future, under MN Statutes §15.472 for fees and expenses arising out of this case. AdeEMPLOYER Representative MNOSHA 'epresentative Title OMT Director Title Date Signed �� ��D Date Signed NOTICE TO EMPLOYEES Any employee or authorized employee representative who has an objection to the above referenced Citation and Notification of Penalty may contest the citation within 20 calendar days of the employer's receipt of it, in accordance with the instructions on page 3 of the Citation and Notification of Penalty. In addition, any employee or authorized employee representative who has an objection to the Citation and Notification of Penalty as amended by this agreement may contest the amended citation within 20 calendar days of the posting of this Settlement Agreement. COMPLETE ANORETURN THIS FORM WIOIN 30 DAYS y aa MANDATORY PROGRESS REPORT -eturn to: Minnesota OSH Division For Office Use Only 443 Lafayette Road oComplete St. Paul,Minnesota 55155 olncomplete ❑Extension Request Phone: (651) 296-2116 FAX: (651) 297-2527 n accordance with MN Rule 5210.0532,this report MUST be returned to the Area Office designated above. Failure to submit all require, •rogress reports will result in an additional citation, penalty,and/or followup inspection.The completed Progress Report Form is to Le ailed by the latest abatement date on the citation, or within 30 days after receipt of the citation,whichever is earlier. Additional reports if necessary) are to be sent at 30 day intervals until all items have been fully abated. rrom: THOMAS MELENA Inspection No. OAK PARK HEIGHTS, CITY OF OSHI ID 14168 OAK PARK BLVD N OAK PARK HEIGHTS MN Optional Report No. Jobsite: 87736 015-00 303889026 (G5082-2007 FILL IN ONE Citation Abatement Date Abated Anticipated and Item - L Action Taken - • Date on (Corrected) Completion Date No. Citation (See Note) NOTE: If the anticipated completion date is beyond the date by which the alleged violation must be abated,you must submit a separat= written Petition for Modification of Abatement Date (PMA)to request an extension of time allowed for completion. See the instructor for a PMA on page 2 of the Citation and Notification of Penalty. A copy of this Progress Report must be posted for 15 days where the citation and notification of penalty is posted and all affect employees and their representatives must be informed of their right to examine and copy all abatement documents submitted to t Commissioner. I hereby certify that this information is accurate. Completed by: Title: Telephone: Date: (Revised 4/98) EXAMPLE ON BACK • COMPLETE ANPET URN THIS FORM WITHIN 30 DAYS osha MANDATORY PROGRESS DE:741TI EN7 Cf LA�i AND*Dara REPORT Return to: Minnesota OSH Division For Office Use Only ?# 1=aayette Road ❑Complete 5t. Paul,Minnesota 55155 ❑Incomplete ❑Extension Request Telephone: 651/296-2116 Fax: 651/297-2527 In accordance with MN Ru 621 .p 32, this report MUST be returned to the Area Office designated above. Failure to submit all required progress reports wiib.,yrilt in an additional citation, penalty, and/or followup inspection. The completed Progress Report Form is to be mailed by thejEst abatement date on the citation, or within 30 days after receipt of the citation, whichever is earlier. Additional reports,(tinac, ssary) are to be sent at 30 day intervals until all items have been fully abated. • From: Company Name �J Ni Company Address Inspection No.300000000 City, State Zip OSHI ID: S9999 • Optional Report No. 001-98 Jobsite: off`. < :< FILL IN ONE Citation .Action` aken Abatement Date Anticipated and Item Date on Abated Completion Date No. . Citation (Corrected) (See Note) 1-1 Safety goggle eye protection has been provided to workers in 7/10 7/6 washer area. 1-2 Fan removed from site• no longer available .`. '' • %1ii iii 9 b e ar u5 �' 7/1 Q 7/3 1-3 Shower/eyewash station installed 8/10 8/2 2-1 Right-to-Know program written 7/21 7/17 a. MSDSs consolidated; missing MSDSs requested from mfrs 8/10 9/1 b, training program updated and being conducted by departrr ert:::*4::.. 8/10 9/1 c. training records updated; maintenance system established:::;' 7/21 7/21 7/17 d. training will be conducted for all new employees upon hire:i '' 7/21 .7/17 l 2-2 Respirator removed from work area and no longer available f(!rfi use; 7/21 7/3 written respirator program no longer required. OTE: If the anticipated completion date is beyond the date by which the alleged violation must be abated,you must submit a eparate written Petition for Modification of Abatement Date (PMA) to request an extension of time allowed for completion. See nstructions for a PMA on page 2 of the Citation and Notification of Penalty. • copy of this Progress Report must be posted for 15 days where the citation and notific :`ion of penalty is posted and all affected mployees and their representatives must be informed of their right to examine and co"' all abatement documents submitted to he Commissioner. hereby certify that this information is accurate. Completed by: Title: �::!j, aF':.r.:::::::::::::::::::::::::iTelephone: Date: -evised 4/98) INr;r�._:: .m..l i1ilinnesota Inspection Number: Department of Labor and Ind> •y OSHI ID: • Optional Report No.: Occupational Safety and Health Division 443 Lafayette Road Employer's Name and Mailing Address St. Paul, MN 55155-4307 Phone: (651) 296-2116 FAX: (651) 297-2527 NOTICE OF CONTEST AND SERVICE TO AFFECTED EMPLOYEES r URPOSE OF THIS FORM is Notice of Contest and Service to Affected Employees form (Notice of Contest form) should ONLY be completed by an -mployer who has received a Citation and Notification of Penalty from the Minnesota Occupational Safety and Health Division MNOSHA), who wishes to contest that a violation occurred, the type of violation, the proposed penalty and/or the date by hich the violation must be abated. f the employer only wishes to obtain an extension of time to abate the violation, the employer may file a Petition for lodification of Abatement Date according to the instructions on the Citation and Notification of Penalty. :y filing this Notice of Contest form, the employer is initiating a formal contested case proceeding before an administrative law udge of the parts of the Citation and Notification of Penalty it is contesting. This form must be filed in good faith and not solely or delay or avoidance of penalties. pon receiptof a timely-filed Notice of Contest form, MNOSHA will contact the employer and schedule a date, time and ocation for an informal conference. The purpose of the informal conference is to allow the employer to discuss with a NOSHA representative the Citation and Notification of Penalty and the basis for the employer's contest. The goal of the nformal conference is to reach an early informal resolution of the contest. If the employer and MNOSHA are unable to reach resolution at the informal conference then the contest will proceed to a formal contested case hearing. MING THIS FORM 's Notice of Contest form must be filed with the Commissioner of the Department of Labor and Industry at the above address ithin 20 days after the date the Citation and Notification of Penalty is received by the employer. To be considered filed, all arts of the Notice of Contest form must be completed and the completed form must be deposited in the United States is ail and postmarked, or otherwise timely received by the Commissioner at the above address within 20 days after the ate the Citation and Notification of Penalty is received by the employer. Facsimile (FAX) transmittal of this form is cceptable, followed by receipt of the mailed original within 5 days. If the employer fails to file the Notice of Contest form In time, the Citation becomes a final order of the Commissioner which is not subject to review by any court or agency. OMPLETING THIS FORM . HOW TO IDENTIFY THE INSPECTION BEING CONTESTED. e employer must complete the box at the top of page 1 of this form using the Inspection Number, OSHI ID, Optional Report umber and Employer's Mailing Address from the Citation and Notification of Penalty being contested. . HOW TO POST AND SERVE THIS FORM. he employer must post a fully completed copy of both pages of this form where the contested Citation and Notification of 'enalty is posted no later than the last day this form may be filed. The form must remain posted until the date of the formal ontested case hearing or earlier final resolution of the contest. there are any affected employees who are represented by an authorized employee representative, the employer shall, on or efore the date this form is required to be filed with the Commissioner, serve a fully completed copy of the form upon the presentative. Service may be accomplished by either postage prepaid first class mail or personal delivery. (Revised 8/97) • 3. DATE OF POSTING. The employer st certify in Box A or B below the datesswhich itosted and served P this form. A. Employers who have-affected Employees B'. Employers who have affected Employees:;Not. Represented By Authorized Employee Represented by Anthonzed Employee Representatives (union) Representatives I hereby certify that I posted fully completed copies I hereby certify that I posted fully completed copies of this form on / / (date) of this form on / / (date) at the locations where the Citation and Notification at the locations where the Citation and Notification of Penalty is posted; and I served fully completed of Penalty is posted and that I do not have any copies of this form on / / (date) affected employees who are represented by upon the authorized employee representatives of authorized employee representatives. affected employees. 4. HOW TO CONTEST THE CITATION AND NOTIFICATION OF PENALTY. The employer must indicate in the boxes below which part of the Citation and Notification of Penalty it wishes to contest. First the employer must identify the citations it is contesting by indicating the citation and item numbers. (For example, "Citation 1, Item 2"). Then the employer must indicate which parts of each item is being contested. Finally, the employer must state the reasons for contesting in the space provided below the boxes. • Check the box under the heading CITATION, if the employer wishes to contest that the violation occurred. • Check the box under the heading TYPE OF VIOLATION, if the employer wishes to contest the characterization of the violation as non-serious, serious, willful or repeat. • Check the box under the heading ABATEMENT DATE, if the employer wishes to contest the date by which you must abate the violation. • Check the box under the heading PENALTY, if the employer wishes to contest the amount of the penalty. FAILURE-TO CHECK ANY PART WILL-RESULT IN THAT PART OF THE CITATION BECOMING A FINAL ORDER OF THE COMMISSIONER WHICH IS NOT.REVIEWABLE BY ANY COURT OR AGENCY. CITATION CITATION TYPE OFABATEMENT PENALTY NUMBER • VIOLATION DATE. AND;, %ITEM NUMBER I contest that a I contest the I contest the I contest the Violation occurred Type of Violation Abatement Date Amount of the Penalty_ • REASONS FOR CONTEST: (additional sheets may be attached as necessary) 5. OATH The employer completing this form must sign and have notarized the following statement. I SWEAR THAT THE INFORMATION PROVIDED ON THIS FORM AND ATTACHED TO THIS FORM IS ACCURATE AND TRUTHFUL TO THE BEST OF MY KNOWLEDGE. Subscribed and sworn to before me this Name of Employer Representative Title date of , 19_ Notary Public ( ) My Commission expires ,19_ Phone Signature Date r • Minnesota Department of Labor and Industry Occupational Safety and Health Division 443 Lafayette Road • St. Paul, MN 55155-4307 Phone: (651)296-2116 FAX: (651) 297-2527 '++u �1 Citation and Notification of.Penalty To: Inspection Number: 303889026 Oak Park Heights, City of OSHI ID: B7736 14168 Oak Park Blvd. No. Optional Report No.: 01500 Oak Park Heights, MN 55082-2007 Inspection Date(s): 12/06/2000 - 12/06/2000 Inspection Site: Issuance Date: 01/04/2001 14168 Oak Park Blvd. No. The uiolati©n(,$)described rn this Citation Nottf c ion Oak Park Heights, MN 55082-2007 of Penalty is (are)alleged to have occurred on or about the.: ttay(s) the inspection;,was made unless otherwise indicated within the descrzotott given below This Citation and Notification of Penalty (this Citation) describes violations of the Minnesota Occupational Safety and Health Act of 1973 (the Act). The penalty amounts listed herein are based on these violations. You must abate the violations referred to in this Citation by the dates listed and pay the penalties, unless within 20 calendar days from your receipt of this Citation you file a Notice of Contest with the Commissioner of the Department of Labor and Industry. Your contestation rights and other employer and employee rights and responsibilities are set out in the first three pages of this Citation. The description of alleged violations begins on page 4 of this Citation. EMPLOYER AND EMPLOYEE RIGHTS AND RESPONSIBILITIES Posting - The Act requires that a copy of this Citation shall be promptly posted at or near each place that an alleged violation referred to in the citation occurred. If uncontested, this Citation must remain posted until all alleged violations cited therein are corrected, or for 20 days, whichever is longer. If contested, this Citation must remain posted until the contestation is resolved. Penalty Payment- Payment of all penalties is to be made by check or money order payable to "Minnesota Department of Labor and Industry" and remitted to the Occupational Safety and Health Division at the address above within 20 calendar days following receipt of this Citation. After 60 days, unpaid penalties shall increase 25 percent and shall accrue an additional interest of 10 percent per month compounded monthly until the fine is paid in full. Citation and Notification of Penalty Page 1 of 10 MNOSHD-2 (Rev. 1/95) • • Notification of Corrective Action - Progress reports on correction of alleged violations not immediately abated shall be submitted on the Progress Report form provided with this Citation. Written progress reports must be submitted to the Area Office indicated in the cover letter accompanying this Citation within 30 calendar days of the issuance date. Reports must state the specific corrective action taken on each cited item, the date of such action and the anticipated abatement date of uncompleted items. Additional written progress reports shall be submitted every thirty days until the items are fully abated. Facsimile (FAX) transmittal is acceptable. All alleged violations not contested must be corrected by the abatement date specified in this Citation. A followup inspection may be made for the purpose of ascertaining that the employer has corrected the alleged violations and posted this Citation as required by the Act. Failure to correct an alleged violation by the abatement date on this Citation may result in further penalties for each day the alleged violation has not been corrected. Petition for Modification of Abatement Date (PMA) - If, due to factors beyond reasonable compliance cannot be achieved by the abatement day on the citation, the employer may file a Petitionsrolfor Modification of Abatement Date (PMA) to obtain an extension of the abatement time period. The PMA must be in writing and received by the Area Office at the address indicated in the cover letter prior to the expiration of the abatement date on the citation. Facsimile (FAX) transmittal of a PMA is acceptable. A copy of the PMA must be posted for ten days in the location where this Citation is posted. A copy of the PMA must also be served upon authorized employee representatives. The employer's written petition must describe: 1) The action that has been taken so far to achieve compliance; 2) The amount of additional time needed for compliance; , 3) The reasons why additional time is needed; 4) A description of the interim steps that will be taken to safeguard employees against the cited hazard; 5) A statement that employees have been notified of the PMA filing. Employees have the right to file a written objection to the Commissioner regarding the employer's PMA request. A copy of the objection must be served on the employer within 10 days of the employer's posting of the PMA. The employee objection must be received by the Commissioner within 15 days of the employer's PMA request. Facsimile (FAX) transmittal is acceptable. Employer Right to Contest - The employer has the right to a hearing to contest any or all parts of this Citation. If the employer wishes to contest, the employer must fully complete and notarize the attached NOTICE OF CONTEST AND SERVICE TO AFFECTED EMPLOYEES (Notice of Contest form) and file it with the Commissioner at the address shown on page 1 of this Citation within 20 calendar days of receiving the citation. Important: To be considered filed, all parts of the Notice of Contest form must be completed and the completed form must be deposited in the United States mail and postmarked, or by the Commissioner at the above address within 20 days after thedate this Citation ese received received the employer. Facsimile (FAX) transmittal is acceptable, followed by the mailed original employer fails to file the Notice of Contest form on time, this Citation and Notification of wipenalty becomess. a final order of the Commissioner which is not subject to review by any court or agency and the Occupational Citation and Notification of Penalty Page 2 of 10 MNOSHD-2 (Rev. 1/95) • • Safety and Health Division may file and enforce the penalty as a district court 'u notice or additional proceedings pursuant to Minnesota Statutes 16D.17. judgment without further Employee Right to Contest - An employee or authorized representative of employees has the right to a hearing to contest this Citation by filing a letter with the Commissioner of the Department of Labor and Industry at the address shown on page 1 within 20 calendar days of the employer's receipt of this Citation. Important: To be considered filed, an employee letter of contest must be depostied in the United States mail and postmarked, or otherwise timely received by the Commissioner at the above address within 20 days after the date this Citation is received by the employer. Facsimile (FAX) transmittal is acceptable, followed by the mailed original within 5 days. If the employee fails to file a letter of contest on time, this Citation and Notification of Penalty becomes a final order of the Commissioner which is not subject to review by any court or agency and the Occupational Safety and Health Division may file and enforce the penalty as a district court judgment without further notice or additional proceedings pursuant to Minnesota Statutes 16D.17. Employee Right to Party Status - Affected employees or their authorized employee representatives may elect to participate as parties in the formal contested case hearing before the start of the hearing by filing written notice with the Commissioner at the address shown above. The notice must contain the employees' names, addresses, authorized employee representatives, if any, and a statement that they are affected employees of the cited employer. Employer Discrimination Unlawful-Employees who believe that they have been discharged or otherwise discriminated against by any person because the employees have exercised any right authorized under the provisions of Minnesota Statute § 182.674, may, within 30 days after such alleged discrimination occurs, file a complaint with -the Commissioner of the Department of Labor and Industry at the address shown above,alleging the discriminatory act. Citation and Notification of Penalty Page 3 of 10 MNOSHD-2(Rev. 1/95) • S Minnesota Department of Labor Inspection Number: 303889026 Occupational Safety and Health Divisiondt� pection Dates: 12/06/2000 - 12/06/2000 °°moi '??. ,.: Issuance Date: 01/04/2001 *� •��•;q�_ CSHO ID: B7736 = Optional Inspection Nbr: 01500 ti - Citation and Notification of Penal Company Name: Oak Park Heights, City of Inspection Site: 14168 Oak Park Blvd. No., Oak Park Heights, MN 55082-0007 Citation 1 Item 1 Type of Violation: Serious 29 CFR 1910.27(d)(2): Fixed ladder(s)used to ascend to heights exceeding 20 feet, and where cages o not provided, were not provided with a landing platform for each 20 feet of height or fraction g r wells were tion thereof: Employees ascend and descend fixed ladders inside water tower#1 which extend 24 ft., 76 ft. and vertically and do not contain the required number of landing platforms or any other related ladder 35 ft. safety ty .......... .40 .............::::}}}}}i}}:J}}•.v::::}i;:}::??•:?•i}}}}'::::::}}}}:v::::iij.}}}�.i}}:::::::}:•}}i:v:::::;}:::iiy:},vr,?::...............:::. ......::: ....:::.... .Ar..}}:..v:.... ... ......v.......v.r...:..:iilii?.::i::J::v i i�::}f'i::::..vvo See pages 1 through 3 of this Citation and Notification of Penalty for information on employer and employee rights and responsibilities. Citation and Notification of Penalty Page 4 of 10 MNOSHD-2 (REV. 1/95) III • Minnesota Department of L Inspection Number: 303889026 abor and Industry Inspection Dates: 12/06/2000 Occupational Safety and Health Division Issuance Date: 01/04/2001 les*- 12/06/2000 ..°' '• CSHO ID: B7736 i� :` .3' Optional Inspection Nbr: 01500 �.�~ ��s "jam' Citation and Notification of Penalt Company Name: Oak Park Heights, City of Inspection Site: 14168 Oak Park Blvd. No., Oak Park Heights, MN 55082-0007 Citation 1 Item 2 Type of Violation: Serious 29 CFR 1910.151(c): Where employees were exposed to injurious corrosive materials, suitable facilities foruic drenching or flushing of the eyes were not provided within the work area for immediate emergency use: q k No eyewash station was available where Hach SPADNS Reagent for Fluoride with a pH <.5 is dispensed. Abatement Note: An eyewash capable of furnishing fifteen minutes of flushing fluid to the eyes should be made available for emergency use within ten seconds of the hazardous work area. Eyewashes and showers should be located as closeu as possible to the hazard, and on the same level. The more hazardo the material, the closer in time and-distance the unit should be. For strong acids (pH<1) orbasses (pH> 12), the unit should be immediately adjacent to the hazard. The eyewash should be designed so that both hands can be free to assist in the irrigation of the eyes. The flushing fluid erature should be tepid or lukewarm (between 60°F and 95°F) and should not exceed 100°F. The water pressure should not exceed 25 pounds per square inch (PSI). Diflatki .:::.:.:;;.::.. .:::>:.;::.; ::::.;.:.:•::: .;::..::::,;::0014.1.15 ::.. .::;::. .; i::::::::•:.i:.:.:.;•:::.:>iii:•:::::>;;>;;:::::.:.;;;:•:.: ii•: : .:. .:..:::.::.: 4iT??::iii:: ..............�:._::::::::i:.iiiiJilii:;:::ii::fi;:i:i$i::::i::i::iii::::i:i:ilii'.T::::::::::�::)':::�::ii::::i i��:::::iii:;:�::.':: si::iiiii::�.<�::!•i i:�iji::i�f� ''�ijiXii YP... .. See pages 1 through 3 of this Citation and Notification of Penalty for information on employer and employee rights and responsibilities. Citation and Notification of Penalty Page 5 of 10 MNOSHD-2 (REV. 1/95) ID • Minnesota Inspection Number: 303889026 Department of Labor and Industry Inspection Dates: 12/0 Occupational Safety and Health Division 12/06/2000 - 12/06/2000 :`ta,�=DU„;.• Issuance Date: ` �''p,�, O1/04/2001 ,A..41,__,,......_ CSHO ID: B7736 i ..Optional Inspection Nbr: 01500 �:`+v. ' 4 di a ' 1 Citation and Notification of Penalty Company Name: Oak Park Heights, City of Inspection Site: 14168 Oak Park Blvd. No., Oak Park Heights, MN 55082-0007 Citation 1 Item 3 Type of Violation: Serious 29 CFR 1910.242(b): Compressed air used for cleaning purposes was not reduced to less than 30 p.s.i.: Air-guns used for cleaning purposes in the public works garage / shop were operated at air pressures above 30 p.s.i.. •}.:• :t ii .i::ii'Wh1:b ;ii a ' ' ::>:} ::'. :i<:::: ..{.i; tig ..gi;.}::{.};.iii::i; i;::{.}}:}:.i:<:;:is}::}}}::}:.}:.:::::.•..:}•.. .0 •01 ;v}v. ................ {.%:i:{:;}ii:4i:i:i i;:iiiiiii{•}:{{•}:i:}::i:}:iii:•}:{•}i{}i'ii:•:{::ii;{•}}:}:}ilii;;LL6;•}iiiiii?J:•i;•i:}:4:{{::}:ilii}::iii{';4;.}}iiiiiii;:{i${•}:{�±'ii'ii::r{}:{n{}i�i$' v;:.......... ..v:.:•.. :::: ::::.v�.}i}}:{moi}v:.v::::{4;•}}i:{•};::{.:::{J;•}i}i}i'::::::::i}}i}:viv:::::::4i}:{•ii:{::::.:�::}}:4;{;::::::::;}:ti6}i;•}w:;:.:}:�.}}:i•}i}:::::::::::•i:}}i'.. ............................................................::i::f;:}:i'}iii'ii:{iii}iii}i;;iiti:••S:i:?}:ii:isiiii:'{:isiiiihi::,{:•:::'r::::::isii::i::iiii:::i::_:ti:i::ii:}:i}:ry;::i::ti::ii:C:i::i`.:iiv::i ''. 4}iii}iiiiii}:.......:::::::::::.w::nv:4i}:{4:4}}:i.}}}:4i: ................::}::::::::::::n4}:::::::::nv::::•}}i'::::::::::••.::::.....::.:vrv::v:....:::::}::: i.::M1::'v.?ti:' ';;i'i.}•;.} .;. .................::v::::::vv::iv•:}:tii:•}:•}i}i}:�:iiitii:::ii::{�v::•ii:i{ti}•}}:•::y:v}::: }'�:v :. :^ Citation 1 Item 4 Type of Violation: Serious 29 CFR 1910.304(f)(4): The path to ground from circuits, equipment, and enclosures was not permanent and continuous: The grounding pin was missing from the three wire cord on the Advance Hydro "wet or dry” vacuum cleaner. ' ''�'t'':i' .:.i::::i;• i::.::.:{:' ::::::i: :i i :• .: :•ii •. ... ;.{.:•;i?:;ti:i{.v�'::;}:;y{{tii};::i;t�:;:}v......:.v;\::::::::...:::::::::::::}:.::.:. •.v:::.... .... ..:....::: .i*,,,•aii•{.};e:,::{.iix.}i:::.}}:.;ix{•.:.i.i:{::;•}:iii:.4Fi{•i:.::.x.::.i:.}:.}.:.i'.:{;•};:{•iiii}::;::.:..:.:.i:.i::•;;>:i::.iii:.:.:::.:.}:.:.}i:•}:::.;}i:.}:.i:.:;•s.:.:{.::.::.::::.,„in: : :.}• ' . ..:'{ ......................:::n:liii::{.::.}i:.i:.:::>::>g:::i>i::ii initM See pages 1 through 3 of this Citation and Notification of Penalty for information on employer and employee rights and responsibilities. Citation and Notification of Penalty Page 6 of 10 MNOSHD-2 (REV. 1/95) i • Minnesota Department of Labor Inspection Number: 303889026 Occupational Safety and Health Industry Inspection Dates: 12/06/2000 - 12/06/2000iffOre4;41,4•21W1. ;..:-.ion Issuance Date: 01/04/2001 CSHO " P'� ID: B7736f ;fig Optional Inspection Nbr: 01500 `=c •': J�` -- Citation and Notification of Penalty *' ; Company Name: Oak Park Heights, City of Inspection Site: 14168 Oak Park Blvd. No., Oak Park Heights, MN 55082-0007 Citation 1 Item 5 Type of Violation: Serious 29 CFR 1910.332(b)(1): Employees were not trained in and familiar with the practices required by 29 CFR 1910.331 through 29 CFR 1910.335 that pertained to respectiveework assignments: their job Electrical switch on a post by `water tower #1 was not in a secured enclosure re and was not Valkentakingfititiffittertiafi •:14'iris::$:ii}}}i?i:i':.}.'•'r:}imi :::}:•::::}S::v:::}:?i4}}:i:}(ti}}}:.}::i}ii{.}:}i}i}i}: .:..:::......:::.......::; r.:. :.A. { iv.:i is�:::. .......................:::.......::.......;:;......:::.......'.:ii}:•i::iii}}}:•ii::i:::i}i}i}:•}T::Q:•}i}:•:•Y;:i•:i;nisi::isP}i}}::.{;;i:{{•}}}}:;:'.:i iii ;v i :::::}:•.v...r. .. .*,......:• ..........:�:::.::::}}:•}}}:::::iii:.:{•};{i:+Y}:•}i;4j}:::}:i•}iii:t::::iIX:L:ii;i}}}}i::}:})::.:ni;::ii}:•}}:4t::iii}}}}}i::}-j::ii}}}}::irry:�. :v....vw::} :. See pages 1 through 3 of this Citation and Notification of Penalty for information on employer and employee rights and responsibilities. Citation and Notification of Penalty Page 7 of 10 MNOSI D-2 (REV. 1/95) • IIII Minnesota Department Inspection Number: 303889026 P of Labor and Industry Inspection Dates: 12/06/2000 Occupational Safety and Health Division - 12/06/2000 Issuance Date: 01/04/2001 1,;!...:;.,.."`"'Z',4'• CSHO ID: B7736 . gin Optional Inspection Nbr: 01500 1%,..:.... ."..-..44'"------OisTr-t.")) 6858+ Citation and Notification of Penalt Company Name: Oak Park Heights, City of Inspection Site: 14168 Oak Park Blvd. No., Oak Park Heights, MN 55082-0007 Citation 1 Item 6 Type of Violation: Serious Minn. Rules 5206.0700 subp.2: The employer did not implement Right-to-Know training for employees who were routinely exposed to hazardous substances: The employer has not established RTK training for employees exposed to hazardous substances that would include but not be limited to gasoline,fuel oil, chlorine, fluorosilicic acid, SPAN reagent for fluoride, insecticides, pesticides and herbicides. DS Abatement Guidelines: The employer must conduct initial and ongoing evaluations of the workplace to determine the hazardous substances for which there is a reasonable potential for employee exposure during the normal course of assigned work. A written Right-to-Know program must be developed and implemented which describes how the training, availability of information, and labeling requirements will be met. Employees must be provided with training in a manner which can be reasonably understood by them, and which addresses the required topics outlined in 5206.0700, Subpart 2. Training is to be provided at the cost of the employer. Records of training provided under this section must be maintained by the employer and retained for 3 years. The written Right-to-Know program shall include: 1) A description of how the training, availability of information, and labeling provisions will be met for the workplace as a whole or for individual work areas. 2) A list of the hazardous substances known to be present using an identity that is referenced on the appropriate material safety data sheet. A list of frequent tasks that expose employees to physical agents and method the employer will use to inform employees. The list may be compiled for the workplace as a whole or for individual work areas. See pages 1 through 3 of this Citation and Notification of Penalty for information on employer and employee rights and responsibilities. Citation and Notification of Penalty Page 8 of 10 MNOSHD-2 (REV. 1/95) • • Minnesota Department of LaborInspection Number: 303889026 Department t of and Industry Inspection Dates: 12/06/2000 - 12/06/2000 i�'•' .,-., Safety and Health Division Issuance Date: 01/04/2001 ''':9 CSHO m: B7736 ~� Z2 Option Inspection Nbr: 01500 ,," tr Citation and Notification '' ' of Penalt Company Name: Oak Park Heights, City of Inspection Site: 14168 Oak Park Blvd. No., Oak Park Heights, MN 55082-0007 3) The methods the employer will use to inform employees of the hazards of infrequent tasks that involve exposure to hazardous substances and the hazards associated with hazardou contained in unlabeled pipes in their work areas. s substances 4) Additionally, in multiemployer workplaces where the employer produces, u ss or stores substances in such a way that employees of other employers may be exposed,the written fight-to- Know program developed and implemented under Minn. Rules 5206.0700ub Right-to- Know Subp.p. 1(b) shall a) the:methods the employer will use to provide the other employers with a copy material safety data sheet, or to make it available at a central location in the worko f a ee for each hazardous substance the other employers' employees may be exposed to while hale working; _ b) the methods the employer will use to inform the other employers cautionary measures that need to be taken to protect employees during normal peratingconditions and in foreseeable emergencies; and c) the methods the employer will use to inform the other employers of the labeling used in the workplace. system The Ri.ht-to-Know trainin• 'ro.ram for hazardous substances shall include: 1) the name or names of the substance including commonly used name; an Y generic or chemical name, trade name, and 2) the level, if any and if known, at which exposure to the substance has been res to standards adopted by the commissioner, or, if no standard has been adopted,ctacco dm accordingto o guidelines established by competent professional groups which have conducted resear g determine the hazardous properties of potentially hazardous substances; ch to 3) the known acute and chronic effects of exposure at hazardous levels, includingroutes 4) the known symptoms of the effects; of entry; 5) any potential for flammability, explosion, or reactivity of the substance; 6) appropriate emergency treatment; 7) the known proper conditions for use of and exposure to the substance; 8) procedures for cleanup of leaks and spills; 9) the name, phone number, and address of a manufacturer of the hazardous substance; and See pages 1 through 3 of this Citation and Notification of Penalty for information on employer and employee rights and responsibilities. Citation and Notification of Penalty Page 9 of 10 MNOSHD-2 (REV. 1/95) 0 • Minnesota Department of Labor Inspection Number: 303889026 and Industry Inspection D Occupational Safety and Health Division ates: 12/06/2000 - 12/06/2000 4ic;0� Issuance Date: 01/04/2001 CSHO ID: B7736 4'—k ;T%. e. . Optional Inspection Nbr: 01500 F.':; � ; Citation and 1 ' Notification of Persalt Company Name: Oak Park Heights, City of Inspection Site: 14168 Oak Park Blvd. No., Oak Park Heights, MN 55082-0007 10) a written copy of all of the above information which shall be readily accessible areas in which the hazardous substance is used or handled. m the area or Records of Ri ht-to-Know trainin shall include: Records of training must be maintained by the employer for three years, and at a 1) the dates training was conducted; minimum, must include: 2) the name, title, and qualifications of the person who conducted the trainin ; s 3) the names and job titles of employees who completed the training; g 4) a brief summary or outline of the information that was included inthe training session. The followin. is the minimum re s uired fre s uenc. of trainin.: 1) before the initial assignment to a job where there is a reasonablepotential course of assigned work, for exposure during the 2) prior to the time an employee may be exposed to any additional hazardous substance 3) training updates, to be provided no less than annually. (s), and fix::::::::::::::::::11::::::.:.:::::::::::.:.::�:::::..: :.:..:.:: :. ..:.. Gretchen B. Maglich Commissioner of the Department of Labor and Industry See pages 1 through 3 of this Citation and Notification of Penalty for information on employer and employee rights and Citation and Notification of Penalty responsibilities. Page 10 of 10 MNOSHD-2(REV. 1/95) •• Minnesota Department of Labor and Occupational Safety and Health Division Industry 443 Lafayette Road Phone: (651)29652 1 1-4307 ? ;•.,, 6 FAX: (651) 297-2527 ` r INVOICEi85s' . Company Name: Oak park Heights, Ci of Inspection Site: 14168 Oak Park Blvd. o, Ming Address= 14168 Oak Park Blvd. No., Oak Park Heights, MN 55082-2007 ' Oak Park Heights, MN 55082-2007 Issuance Date: 01/04/2001 OSS 1W: B7736 Optional Report No,.: 01500 Summary of Penalties for Inspection Number 30388 Citation 1, Serious 9026 t #1' ::>: = $ 1875.00 Penalty Payment- Payment Minnesota De of all penalties is to be Department of Labor and Indust made bh check of money order payable to the order of and Division at within, an20d calendar with t following receipt and Healthid Dvpenalties shall the addressdabove25 perwitent and shall accrue copy this invoice toCitation. the ion. After f Occupational 60 Safety compounded monthlya an additionalinteresta esthisf 10 tPerce er days, P until the fine is paid in full. permonth If any portion of this Citation and Notification of Penalty is contested payable until the resolution of the contestation. � that portion of the penalty uncontested portion of the citation within 20 calendar daysfollyou are owing receipt obligated this d to not due and pay the penalty on the NOTE: The penalties shown above have already been adjusted forP of this Citation. Good Faith, Size and History credits. Page 1 of 1 i .... ..... . - _ sem- 3 a fix 30 ‘16 kto _ ,' 0 \N\\\\\111 1 1111j1j1j, • Q•' UN Nis °6''.'e rR -- Minnesota Departme• nt of Labor and Indus• tryo ..III\ )gtglEOUB Subject: ...\\ `N ` 9 2001 CITATION AND Safety and ealth NOTIFICATION OF Agreement Violations and Eligibility for nal g meat(EISA) ty for Expedited Inforedmal l upe Informal Settlement A recent inspection of a resulted in the enclosed place of e the a place of andmployment under your Minnesota the OccupationalNotification of Penalty operation, instructions listed under Safety and which describes allegedp' or control has the citation BMpLO Health Act of 1973, adfo and the EAIYER AND EMPLOYEE Please read violations of following discussion of your eligibilityfor an AND RESPONSIBILITIES and follow This inspection revealed for an EISA NSIBILITIES on there more thanno instances ofRePeated Health Investigator two high gravity , Willful has Serious violations. ,or Additionally, th Occue-to Abate pational S correct the violations reported that Additional) that were cited,and u have a Y, the nor were specified in the good understanding Safety and Citation and Notification are willingg of the actions of penalty, to make those co necessary to These factors, erections by the dates Expedited Informal with the rural Sie good faith you have e an a 30percentpenal errant Agreement exhibited, make Expedited al reduction by (EISA). Under this program,'company eligible for going throughathe formal entering into an info with rmal contestation informal settlement m, employer can obtain However,if Procedure. agreement with OSHA be awareyou decide to e that you waive nter into an Expedited Informal Settle m enobtain a cannot bvehourright a contest any part o f the taeeinent,you shouldof n EISA on the remainingPortion ofCitation and contestthe Citation and Notification Notification of The EISA can Portion. be used onl of Penalty and penalty. If Q where the sole issue then the EISA wish to discuss, of dispute h is the dollar the t of according to the • used. Underany other aspect of the�'INOSHA Notice cannot be used. those circumstances, a inspectionnotice oofcitations,t of Contest form, contained on the Citation ances, you may and Notification f penalty and °f contest the attached • • You should carefully ne whether the terms of the agreement are acceptable to you Key read the enclosed EISA to determi elements of the agreement include: enalty amount;_ HA agrees to a 30%reduction in the total p . .4: . MN(�S. agrees to post the EISA with the citation; The employerin the citations(an employer - the date shown er agreesan extension of the original abatement date); _ The employer to abate theviolations by Prequest written progress acting in good faith may q evidence of corrective action and submit 0 days thereafter progress agrees to provide and every_ The employer sof citation issuance report to MNOSHA within 30 day all items are abated; amount of the reduced penalty' at the time that the to er agrees to pay the full SHA. The employer mpyEISA is returned to MNOSHA. original signedpenalty(10% of the total original p and payment of reduced days followingyour receipt of the The orifisigned EISA MNOSHAorfs must ybeour submitted e final received by within 2n ca rP "date which the must be o f Penalty. Written progress by o amount) Notification Citation to show that you have completed all corrections as of the shown on the citation. inspection and citation violation must be abated" information on its insp ation Act. publishes inform of Inform You should the aware that Federal OSHA Pdays after the Citation Thee under the provisions of the Electronic calendar Freedomyestablishment at on Internet to concerning your es activityour inspection will be available information information displayed please Date.- Yo related to y the inform of the are encouraged to review You dispute with the accuracy GOV. Ifyouhaveany P ��1.OSHA. reement contact this office. on or this Expedited Informal Settlement Ag questions regarding the citation If you have any 9 651 296-2116. offer,please contact me at(651) Sincerely, Terry Mueller OMT Director • ` „":‘,..,..6.0..14, \.\\,'..`�1'1ryT1 ryITI�I .I • 04,„YW , � �� Minnesota tiw ��� Department of Labor and Industry '4..,:i ;4 Occupational Safety and Health Division In the matter of: Oak Park Heights, City of INSPECTION NO.: 303889026 OSHI ID/OPTIONAL REPORT NO: B7736 015-00 EXPEDITED INFORMAL SETTLEMENT AGREEMENT (Oak Park Heights,City of),by its undersigned representative and Minnesota Occupational Safety and Health Division(MNOSHA)by its undersigned representative, in settlement of the above referenced Citation and Notification of Penalty (CITATION),hereby agree to the disposition of this matter on the following terms: 1. The EMPLOYER agrees to abate the violations as cited, on or before the abatement dates set out in the CITATION. 2. The EMPLOYER agrees to provide evidence of the actions taken to abate the violations by submitting written progress reports to MNOSHA within 30 days of citation issuance and every 30 days thereafter- until all items are abated. 3. Upon correction of all violations,the EMPLOYER agrees to post for a period of three days a copy of the final progress report certifying that all violations have been abated in the place where the CITATION is posted. 4. MNOSHA agrees that the total penalty amount is amended to($1,312.00). The EMPLOYER agrees to submit full payment of the amended amount along with this original signed Settlement agreement within 20 days following the EMPLOYER'S receipt of the CITATION. 5. In consideration of the foregoing amendment,the EMPLOYER hereby waives its right to contest the CITATION pursuant to MN Statutes § 182.661. It is understood and agreed by MNOSHA and the EMPLOYER that the CITATION as amended by this agreement shall be deemed a final order of the Commissioner not subject to review by any court or agency. 6. The EMPLOYER agrees to immediately post a copy of this Settlement Agreement in the same manner and place as the CITATION is required to be posted. The signature of the EMPLOYER representative on this Settlement Agreement is understood to be certification of this posting. 7. In addition to action MNOSHA may take against the EMPLOYER pursuant to Minn. Stat. Ch. 182 (1996)and other remedies provided by law,the EMPLOYER agrees that its failure to comply with any term of this agreement shall cause the original penalty amount of($1,875.00) to become due and owing to MNOSHA. • Expedited Informal Settlement Agreement Page 2 • 8. Each party hereby agrees to bear its own fees and other expenses incurred with and the EMPLOYER further agrees to waive all claims it may , now w ana d in thinproceeding under MN Statutes §15.472 for fees and expenses arising out of this case. the future, / Ade - EMPLOYER Representative MNOSHA Representative Title OMT Director Title Date Signed h Date Signed NOTICE TO EMPLOYEES Any employee or authorized employee representative who has an objection Citation and Notification of Penalty may contest the citation within 20 calendar to the above referencedp receipt of it, in accordance with the instructions on page 3 of the Citation and days of the fPen Penalty. In addition, any employee or authorized employee represeontative Notification of Penalty. and Notification of Penalty as amended by this agreement may contest the bjecitation to the Citation n20 calendar days of the posting of this Settlement Agreement. amended within 20 COMPLETE Alit RETURN THIS FORM i1VII-1IN 30 DAYS j osha MANDATORY PROGRESS REPORT Return to: Minnesota OSH Division For Office Use Only 443 Lafayette Road oComplete St. Paul,Minnesota 55155 ❑incomplete ❑Extension Request Phone: (651) 296-2116 FAX: (651) 297-2527 In accordance with MN Rule 5210.0532,this report MUST be returned to the Area Office designated above. Failure to submit all requirr' progress reports will result in an additional citation, penalty, and/or followup inspection.The completed Progress Report Form is to be mailed by the latest abatement date on the citation, or within 30 days after receipt of the citation,whichever is earlier. Additional repots (if necessary) are to be sent at 30 day intervals until all items have been fully abated. From: THOMAS MELENA Inspection No. OAK PARK HEIGHTS, CITY OF OSHI ID 14168 OAK PARK BLVD N Optional Report No. Jobsite: OAK PARK HEIGHTS MN 55082-2007 67736 015-00 303889026 (GI) FILL IN ONE Citation Abatement Date Abated Anticipated and Item Action Taken Date on (Corrected) Completion Date No. Citation (See Note) NOTE: If the anticipated completion date is beyond the date by which the alleged violation must be abated,you must submit a separat written Petition for Modification of Abatement Date (PMA)to request an extension of time allowed for completion. See the instruction for a PMA on page 2 of the Citation and Notification of Penalty. A copy of this Progress Report must be posted for 15 days where the citation and notification of penalty is posted and all affect. employees and their representatives must be informed of their right to examine and copy all abatement documents submitted to t: Commissioner. I hereby certify that this information is accurate. I Completed by: Trtle: Telephone: Date: (Revised 4/98) EXAMPLE ON BACK O____________________________ COMPLETE AIS RETURN THIS FORM WITHIN 30 DAYS 1 osha MANDATORY PROGRESS REPORT DeiJITVEV cF LA MD INDLSTV ` `' For Office Use Only to: Minnesota OSH Division as ette Road oComplete ., y ` ❑Incom lete St. Paul, Minnesota 55155 P I iEw::.:.:,*i:.:i:.*i1 DExtension Request Telephone: 651/296-2116 Fax: 651/297-2527 In accordance with MN Ru .,:,219;"532,� this report MUST be returned to the Area Office designated above. Failure to submit all required progress reports wi ,pIt in an additional citation, penalty, and/or followup inspection. The completed Progress Report Form is to be mailed by the. st abatement date on the citation, or within 30 days after receipt of the citation, whichever is earlier. Additional reports,(i'nesary) are to be sent at 30 day intervals until all items have been fully abated. `� From: Company Name ` Company Address Inspection No.300000000 City, State Zip OSHI ID: S9999 Optional Report No. 001-98 Jobsite: :>i .,.;.:;>..:. FILL IN ONE Citation - Action` aken Abatement Date Anticipated and Item Date on Abated Completion Date No. Citation (Corrected) (See Note) 1-1 Safety goggle eye protection has been provided to workers in 7/10 7/6 washer area. t-:: :...f:ii iif i:i 1-2 Fan removed from site; no longer available far'u5- 7/10 7/3 1-3 Shower/eyewash station installed 8/10 8/2 2-1 Right-to-Know program written 7/21 7/17 a. MSDSs consolidated; missing MSDSs requested from mfrs 8/10 9/1 b. training program updated and being conducted by departrnert.......:::.. 8/10 9/1 c. training records updated; maintenance system established:;` 7/21 7/17 d. training will be conducted for all new employees upon hire€ :•�' 7/21 7/17 ti 2-2 Respirator removed from work area and no longer available for use; 7/21 7/3 written respirator program no longer required. . NOTE: If the anticipated completion date is beyond the date by which the alleged violation must be abated, you must submit a separate written Petition for Modification of Abatement Date (PMA) to request an extension of time allowed for completion. See instructions for a PMA on page 2 of the Citation and Notification of Penalty. A copy of this Progress Report must be posted for 15 days where the citation and notific . ion of penalty is posted and all affected employees and their representatives must be informed of their right to examine and co all abatement documents submitted to the Commissioner. I hereby certify that this information is accurate. Completed by: Title• }`":,.:,. Telephone: Date: "" "` ', (Revised 4/98) t?1:::<:>::;»>::<::::I 'Minnesota Department of Labor and InInspection Number: •estry OSHI ID: Occupational Safety and Health Division Optional Report No.: 443 Lafayette Road Employer's Name and Mailing Address St. Paul, MN 55155-4307 Phone: (651) 296-2116 FAX: (651) 297-2527 NOTICE OF CONTEST AND SERVICE TO AFFECTED EMPLOYEES PURPOSE OF THIS FOR1' This Notice of Contest and Service to Affected Employees form (Notice of Contest form) should ONLY be completed by an employer who has received a Citation and Notification of Penalty from the Minnesota Occupational Safety and Health Division (MNOSHA), who wishes to contest that a violation occurred, the type of violation, the proposed penalty and/or the date by which the violation must be abated. If the employer only wishes to obtain an extension of time to abate the violation, the Modification of Abatement Date according to the instructions on the Citation and Notificationploof Penalty file a Petition for By filing this Notice of Contest form, the employer is initiating a formal contested case proceeding before an administrative law judge of the parts of the Citation and Notification of Penalty it is contesting. This form must be filed in good faith and not solely for delay or avoidance of penalties. Upon receipt of a timely filed Notice of Contest form, MNOSHA will contact the`e ployer and schedule a date, time and location for an informal conference. The purpose of the informal conference is to allow the employer to discuss with a MNOSHA representative the Citation and Notification of Penalty and the basis for the employer's contest. The goal of the informal conference is to reach an early informal resolution of the contest. If the employer and MNOSHA are unable to reach a resolution at the informal conference then the contest will proceed to a formal contested case hearing.' FILING THIS FORM This Notice of Contest form must be filed with the Commissioner of the Department of Labor and Industry at the above address within 20 days after the date the Citation and Notification of Penalty is received by the employer. To be considered filed, all parts of the Notice of Contest form must be completed and the completed form must be deposited in the United States mail and postmarked, or otherwise timely received by the Commissioner at the above address within 20 days after the date the Citation and Notification of Penalty is received by the employer. Facsimile acceptable, followed by receipt of the mailed original within 5 days. If the employer fails(FAX) thNotice f Cotransmittal of ntest foris m on time, the Citation becomes a final order of the Commissioner which is not subject to review by any court or agency. COMPLETING THIS FORM ' 1. HOW TO IDENTIFY THE INSPECTION BEING CONTESTED. The employer must complete the box at the top of page 1 of this form usingthe Inspection Number, OSH Number and Employer's Mailing Address from the Citation and Notificaon of Penalty being conteestedI ID, Optional Report 2. HOW TO POST AND SERVE THIS FORM. The employer must post a fully completed copy of both pages of this form where the contested Citation and Notification of Penalty is posted no later than the last day this form may be filed. The form must remain posted until the date of the formal contested case hearing or earlier final resolution of the contest. If there are any affected employees who are represented by an authorized employee representative, the employer shall, on or before the date this form is required to be filed with the Commissioner, serve a fully completed copy of the form upon the representative. Service may be accomplished by either postage prepaid first class mail or personal delivery. (Revised 8/97) 3. DATE OF POSTING. The employeest certify in Box A or B below the dates 6n which it posted and served this form. A. Employers who have.affected Employees B. Employers who.have affected Employees:Not. Represented By Authorized Employee Represented by Authorized Employee Representatives (union) Representatives I hereby certify that I posted fully completed copies I hereby certify that I posted fully completed copies of this form on / / (date) of this form on / / (date) at the locations where the Citation and Notification at the locations where the Citation and Notification of Penalty is posted; and I served fully completed of Penalty is posted and that I do not have any copies of this form on / / (date) affected employees who are represented by upon the authorized employee representatives of authorized employee representatives. affected employees. 4. HOW TO CONTEST THE CITATION AND NOTIFICATION OF PENALTY. The employer must indicate in the boxes below which part of the Citation and Notification of Penalty it wishes to contest. First the employer must identify the citations it is contesting by indicating the citation and item numbers. (For example, "Citation 1, Item 2"). Then the employer must indicate which parts of each item is being contested. Finally, the employer must state the reasons for contesting in the space provided below the boxes. • Check the box under the heading CITATION, if the employer wishes to contest that the violation occurred. • Check the box under the heading TYPE OF VIOLATION, if the employer wishes to contest the characterization of the violation as non-serious, serious, willful or repeat. • Check the.box under the heading ABATEMENT DATE, if the employer wishes to contest the date by which you must abate the violation. • Check the box under the heading PENALTY, if the employer wishes to contest the amount of the penalty. FAILURE TO CHECK ANY PART WILL RESULT IN THAT PART OF THE CITATION BECOMING A FINAL ORDER OF THE COMMISSIONER WHICH IS NOT.REVIEWABLE BY ANY COURT OR AGENCY. CITATION CITATION TYPE OF ABATEMENT PENALTY NUMBER VIOLATION DATE;; AND.:: ITEM NUMBER I contest that a I contest the I contest the I contest the Violation occurred Type of Violation Abatement Date Amount of the Penalty REASONS FOR CONTEST: (additional sheets may be attached as necessary) 5. OATH The employer completing this form must sign and have notarized the following statement. I SWEAR THAT THE INFORMATION PROVIDED ON THIS FORM AND ATTACHED TO THIS FORM IS ACCURATE AND TRUTHFUL TO THE BEST OF MY KNOWLEDGE. Subscribed and sworn to before me this date of , 19_ Name of Employer Representative Title Notary Public ( ) My Commission expires ,19_ Phone Signature Date • • Minnesota Department of Labor Occupational Safety and Health and Industry ,� 443 Lafayette Road Division . St. Paul, MN 55155-430715f4x''" _=L� Phone: (651)296-2116 FAX: (651) �� 297-2527 c� t��'*itis^• %'IGa18558 Citation and Notification of Penalty To: Inspection Number: 303889026 Oak Park Heights, City of 14168 Oak Park Blvd. No. OSHI ID: B7736 Oak Park Heights, MN 55082-2007 Optional Report No.: 01500 Inspection Date(s): 12/06/2000 - 12/06/2000 Inspection Site: Issuance Date: 01/04/2001 14168 Oak Park Blvd. No. ofPenal Oak Park Heights, MN 55082-2007 The violation(s)described in this Citation 1roab h Penalty is{are),alleged to have occurred an ar theabout day(s) the inspection was made unless otherwise indicated within the description given below This Citation and Notification of Penalty(this Citation) describes violations of the Minnesota Occupational Safety and Health Act of 1973 (the Act). The penalty amounts listed herein are based on these violations. Y abate the violations referred to in this Citation by the dates listed and pay the penalties, unless within days from your receipt of this Citation you file a Notice of Contest with the Commissioner of the m must Labor and Industry. Your contestation rights and other employer and employee ri h20 calendar out in the first three pages of this Citation. The description of alleged violations begins Department of rights on is and responsibilitiesoare set page 4 of this Citation. EMPLOYER AND EMPLOYEE RIGHTS AND RESPONSIBILITIES Posting - The Act requires that a copy of this Citation shall be promptly alleged violation referred to in the citation occurred. If uncontested, this Citation must remain posted ost d that an alleged violations cited therein are corrected, or for 20 days, whichever is longer. If contested, this Citation must allt remain posted until the contestation is resolved. must Penalty Payment- Payment of all penalties is to be made by check or money ordera abl Department of Labor and Industry" and remitted to the Occupational Safety and Health Division at above within 20 calendar days following receipt of this Citation. After 60 da p Y e to "Minnesota25 percent and shall accrue an additional interest of 10 percent per month compounded oun unpaid penalties shall increase the address paid in full. p led monthly until the fine is Citation and Notification of Penalty Page 1 of 10 MNOSHD-2 (Rev. 1/95) • Notification of Corrective Action - Progress reports on correction of alleged violations not immediately abated shall be submitted on the Progress Report form provided with this Citation. Written progress reports mst be submitted to the Area Office indicated in the cover letter accompanying this Citation within 30 calendar days of the issuance date. Reports must state the specific corrective action taken on each cited item, the date of such action and the anticipated abatement date of uncompleted items. Additional written progress reports shall be submitted every thirty days until the items are fully abated. Facsimile (FAX) transmittal is acceptable. All alleged violations not contested must be corrected by the abatement date specified in this Citation. A followup inspection may be made for the purpose of ascertaining that the employer has corrected the alleged violations an posted this Citation as required by the Act. Failure to correct an alleged violation by the abatement date on this Citation may result in further penalties for each day the alleged violation has not been corrected. Petition for Modification of Abatement Date (PMA) - If, due to factors beyond compliance cannot be achieved by the abatement day on the citation, the employer ay fie a Petitions for Modification of Abatement Date (PMA) to obtain an extension of the abatement time period. The PMA must be in writing and received by the Area Office at the address indicated in the cover letter prior to the expiration of the abatement date on the citation. Facsimile (FAX) transmittal of a PMA is acceptable. A copy of the PMA must be posted for ten days in the location where this Citation is p posted. A copy of the PMA must also be served upon authorized employee representatives. The employer's written petition must describe: 1) The action that has been taken so far to achieve compliance; 2) The amount of additional time needed for compliance; 3) The reasons why additional time is needed; 4) A description of the interim steps that will be taken to safeguard employees against the cited hazard; 5) A statement that employees have been notified of the PMA filing. Employees have the right to file a written objection to the Commissioner regarding the employer's PMA request. A copy of the objection must be served on the employer within 10 days of the employer's posting of the PMA. The employee objection must be received by the Commissioner within 15 days of the employer's PMA request. Facsimile (FAX) transmittal is acceptable. q Employer Right to Contest - The employer has the right to a hearing to contest Citation. If the employer wishes to contest, the employer must fully complete and notarize the attached NOTICE OF CONTEST AND SERVICE TO AFFECTED EMPLOYEES (Notice of Contest form) and file it with the Commissioner at the address shown on page 1 of this Citation within 20 calendar days of receiving the citation. Important• To be considered filed, all parts of the Notice of Contest form must be completed and the completed form must be deposited in the United States mail andro _ by the Commissioner at the above address within 20 days after the date this Citation e�received byre employer. Facsimile (FAX) transmittal is acceptable, followed by the mailed ori employer fails to file the Notice of Contest form on time, this Citation and Notification f p�days. If the a final order of the Commissioner which is not subject to review by any court or agency and the Occupational Citation and Notification of Penalty Page 2 of 10 MNOSHD-2 (Rev. 1/95) • • Safety and Health Division may file and enforce the notice or additional proceedings pursuant to penalty as a district court 'ud Minnesota Statutes 16D.17. judgment without further Employee Right to Contest - An employee or authorized representative of employees has the right to a hearing to contest this Citation by filing a letter with the Commissioner of the Department of Labor and Industry at the address shown on page 1 within 20 calendar days of the employer's receipt of ��nortant• To be considered filed, an employee letter of contest p this Citation. and Postmarked, or otherwise timely received byCommissioner the must be depostied in the United States mail the date this Citation is received by the employer. Facsimile at the above address within 20 days after mailed original within 5 days. If the employee fails to file letter trof contest acceptable,time, thisfollowed by the Notification of Penalty becomes a final order of the Commissioner which is not or agency and the Occupational Safetyon time, Citation and and Health Division may file and enforce thect e penalty review by and court court judgment without further notice or additional proceedings g pursuant to as a district Employee Right to PartyMinnesota Statutes 16D.17. Status - Affected employees or their authorized employee representatives elect to participate as parties in the formal contested case hearing before the start of notice with the Commissioner at the address shown above. The notice must containmay addresses, authorized employee representatives, if any, the hearing by filing written employer. and a statement that they are affected employees emeof eaci ed Employer Discrimination Unlawful-Employees who believe that discriminated against by any person because the employees have exercised anythey right authorizedbeen dischargedunder the otherwise of Minnesota Statute§ 182.674,may, within 30 days after such alleged discrimiation occurs, file ar faint with act.ce Commissioner of the Department of Labor and Industry at the address shown a o allegingle discriminatoryompnt dye, the Citation and Notification of Penalty Page 3 of 10 MNOSHD-2(Rev. 1/95) ! S Minnesota Inspection Number: 303889026 O Department pl s of Labor and Industry Inspection Dates: 12/06/2000 12/06/2000 .•, Safety Health Division Issuance 01/04/2001 Date: CSHO ID: B7736 Bei Optional Inspection Nbr: 01500 =•. +lei Citation and Notification of Penalty Company Name: Oak Park Heights, City of Inspection Site: 14168 Oak Park Blvd. No., Oak Park Heights, MN 55082-0007 Citation 1 Item 1 Type of Violation: Serious 29 CFR 1910.27(d)(2): Fixed ladder(s)used to ascend to heights exceeding 20 feet, and where cages or wells were not provided, were not provided with a landing platform for each 20 feet of height or fraction thereof: Employees ascend and descend fixed ladders inside water tower#1 which extend 24 ft., 76 ft. and 35 ft. vertically and do not contain the required number of,landing platforms or any other related ladder safety devices. ::{:..�{::�.};v :n:{: :{;A};{%::'v ::.f}:.}:a:.}•'.!:?::iiiti{i:::Y,isi::i;;i{ii.`iiiiQ{isi`::i:}:i:}:}}}}:}}}}}}}};i:::: :::::.w::.:::................... C1iI.: :.{:;:;:; {:: '. iii: j:�i:..• ::iiftiti .}:.}:{{•:}::{;,{>•}iii::ii::::;::><:::::>:: ::::::;>::.:::.:.:::::}:.: :..:... ......:..:: . .}:.:.�.':<:»:}::}>}}>:{�:.;.:::::::;:..::::::........ :; tom> :. ��p '. ...m::::................ .......w::::;. :.ori{•}:•}}}:{{:{•}:: }\ :{+ .�:0}}}:;y;K{6}}:;i•:4}}};•}}::O;•iri::•isiiisi:::i'riiiiiS:}:^::{?:vjiiii:}}}}}}}:•}i}'rii:ii:i:}:4}}{'::4}}ij:{;{}'•}}}:.}i:{•}iiiiiii::iii•}:{{.}:{?}{'}:;:{•i: ...................::::::.w;: ::: ::�:{{•};•}:•}:•}}:•}:{{?iiiiii}}::ti;;:ii:iii:•:iiii::{:iiiiiiiii}i:::i;}y:^};•iii;•i ;•ii:}:•y}}:4;{•}}:{vii::}::ii:{.}:{{?:•}:•}}}}:•::•}:}{:{�}ilii}::{{i$i, .....n:kkMW See pages 1 through 3 of this Citation and Notification of Penalty for information on employer and employee rights and responsibilities. Citation and Notification of Penalty Page 4 of 10 MNOSHD-2 (REV. 1/95) • • Minnesota Inspection Number: 303889026 Department of Labor and Industry Inspection Dates: 12/06/2000 - 12/06/2000 Occupational Safety and Health Division IssuanceDate: �t�o,�.n�„,.. • -. sio 01/04/2001 •`, „ •�CSHO ID: B7736 = :.1)____.,,,-- -�' _Optional Inspection Nbr: 01500 .�” -- +i85s :•. Citation and Notification of Penalty Company Name: Oak Park Heights, City of Inspection Site: 14168 Oak Park Blvd. No., Oak Park Heights, MN 55082-0007 Citation 1 Item 2 Type of Violation: Serious 29 CFR 1910.151(c): Where employees were exposed to injurious corrosive materials, suitable facilities for quick drenching or flushing of the eyes were not provided within the work area for immediate emergency use: No eyewash station was available where Hach SPADNS Reagent for Fluoride with a pH <.5 is dispensed. Abatement Note: An eyewash capable of furnishing fifteen minutes of flushing fluid to the eyes should be made available for emergency use within ten seconds of the hazardous work area. Eyewashes and showers should be located as close as possible to the hazard, and on the same level. The more hazardous the material, the closer-in time and distance the unit should be. For strong acids (pH<1) or bases (pH>12), the unit should be immediately adjacent to the hazard. The eyewash should be designed so that both hands can be free to assist in the irrigation of the eyes. The flushing fluid temperature should be tepid or lukewarm (between 60°F and 95°F) and should not exceed 100°F. The water pressure should not exceed 25 pounds per square inch (PSI). .,:":?:''�"i t ::..�'''':"::>...>::.';�:.:.:;:i::::t: :":..:::;:::.:::::s::ti::ii::::::�:•::."::>::::::iiir:ii;•i:•i:.::: .�:::::::::................ ':...::::::.::.•::ii:::: i.:.::.:...::::::: :'. ..... :.'.. ::::: •: :: ::: .:....ii:.i' <.•:.;':.:::;:::>: :>::::•i:.:;•i:.i:::::::<::i;:<:iiii:is iii�.:::>:::::::.:.� ::..........#60 ........ iant ....ii'i}:!•i:�i};) }i:ii :4:ibi}iiLi;iii}i:•viiiiii:•}iJ:biipii:•iii:::ilii}T:vi;ii}:•:•:Li:iii:4:•?iii:^}ii:4}•:•iii:P}i:?iv:Jy,i:•}:''::•• viii:•:?;:•i:^:4`%: .. :i•:. . :•:.. .................::::::::::::::::.;?•iiiii}>:;a:•:<iS::::::::::::::::i:::::::::;:;:::i:::::::::::::::::::;?:%:;<;:::<;:::::::::#:::;:<::;:%;:;::?::'�:>.:?:%'.'•ii;:::i::'::,,;':; : ::: ':::::;::::::::5'::''>::: `�:ai:: :> See pages 1 through 3 of this Citation and Notification of Penalty for information on employer and employee rights and responsibilities. Citation and Notification of Penalty Page 5 of 10 MNOSHD-2 (REV. 1/95) II • Minnesota Inspection Number: 303889026 Department of Labor and Industry Inspection Dates: 12/06/2000 - 12/06/2000 ''�. '' Occupational Safety and Health Division Issuance 01/04/2001 Date: = .n 4� CSHOID: B7736 l _ Optional Inspection Nbr: 015001. -- Citation and Notification of Penalty Company Name: Oak Park Heights, City of Inspection Site: 14168 Oak Park Blvd. No., Oak Park Heights, MN 55082-0007 Citation 1 Item 3 Type of Violation: Serious 29 CFR 1910.242(b): Compressed air used for cleaning purposes was not reduced to less than 30 p.s.i.: Air-guns used for cleaning purposes in the public works garage / shop were operated at air pressures above 30 p.s.i.. :,:.'�:.::::`i::::::j::.�'''':'i j;:i:.'..:iy;;;:i:.t;:. :.`:::.:yii;i::i:::::::::::i:::::i:•:?::::::.ssi>:'•.::>.»::::.: :::::::::::......................... Citation 1 Item 4 Type of Violation: Serious 29 CFR 1910.304(0(4): The path to ground from circuits, equipment, and enclosures was not permanent and continuous: The grounding pin was missing from the three wire cord on the Advance Hydro "wet or dry" vacuum cleaner. .':.. ::::...:i':i::i:::i;}{:i?{Sii iiisisi::i::::::::i:::::::i::ii::ii::i}::::::::isi::i}i::i::::ii:::::::�::i::{i::::::i::::::i::::::isii:i::i:::ir::::i::i:::::i::i}:::si::i• ::::::::: ::i::i::ii:vi: :r:::::i:i:�::::::i::i::ii::i:::.:}ii::::i:Fii:...{.1.....�:. .. w:i4:Jii4}i ::.:i:L:tr:•i:•iia•ii::::n�:iii}ilii}i:vi'L::::::;:•}}i:3iiiii}i'::::::iii}iii:•iiiii:•a:::::iia i:•i}ii:•ii:::::::::ilii}iii}i:CL:•ii}::::::::iii:L:•iia•i:•ii:•:::::.'•::•iii}iiia:1 •' i,ii •. :fi:v................:.::::::::::::::::::i:•i:^:•iiiiiiii}ii};:i:{:iiiii:i::iiiii:;:;i::ii::::::::iii::j:i:}Jiii:::::::iv:?ii::::::::::i::::::: ':::i:Jiiiii: :i:::::i�ijj?i:::::i::i}j$iii??ji?{i;;::.:!i;!:_j?iiiii;:i .'.'':':•' ': ......:..............:.:::v:::�::: :�:{:i:•i:•i>:•iiiii}ii ::Sii;:i i::i::iiL ii: �:• See pages 1 through 3 of this Citation and Notification of Penalty for information on employer and employee rights and responsibilities. Citation and Notification of Penalty Page 6 of 10 MNOSHD-2 (REV. 1/95) . II Minnesota Inspection Number: 303889026 Department of Labor and Industry Inspection Dates: 12/06/20004s"13.44% Occupational Safety and Health Division - 12/06/2000igsirri..._\Issuance Date: 01/04/2001 �� : CSHO ID: B7736 i_.,,,..,,.wlipc".?:_.: " Optional Inspection Nbr: 01500 . ";W4 ;�. '••...`1158llsi +: Citation and Notification of Penalty Company Name: Oak Park Heights, City of Inspection Site: 14168 Oak Park Blvd. No., Oak Park Heights, MN 55082-0007 Citation 1 Item 5 Type of Violation: Serious 29 CFR 1910.332(b)(1): Employees were not trained in and familiar with the safetyrelated work practices required by 29 CFR 1910.331 through 29 CFR 1910.335 that pertained to their respective job assignments: Electrical switch on a post by water tower #1 was not in a secured enclosure and was not weatherproof. igteikAWINIEVirfifitiO .....:...... ............:::.:.�::•.::::•:moi:iii:•}i:.ii:Siiii::i4iii}i;v:ii;i}iiii:•i}ii::•:,�:.............. ........... Yn......., ........... ...:..:.... .v w„ .. n #}r r �:•.:x(?iisi<:i:::::::is>:Ti::i'ri::i�::ti:'::iiiiiTiiiii'r'::isisiiiiiii'r??:'rSSiiiiiii::ii:::ii:>:i}Y:>iiiJ::iiJiiiiiiiii'iiiii is ri ii'.::i?:i{:ii:i is ii"7ii}jii::i:�::}i:::.... ... :. ....:...........................:.::::::.:.::::::.:.:.•.•.::.:•.•::::::.':.:'::::':•:.+:'.:::.^.{:`.:•:i::::isjii:}?':;:iiiiii::ii ;:y;::::;:i:iiilii}ii:?{;;:;i:ii iii::r::ii:;;i;;i uy i•.�:.�:.:::�.�:::.i..:::v:. See pages 1 through 3 of this Citation and Notification of Penalty for information on employer and employee rights and responsibilities. Citation and Notification of Penalty Page 7 of 10 MNOSHD-2 (REV. 1/95) O • Minnesota Inspection Number: 303889026 Department of Labor ..• Department Safety and Hand Industry Inspection Dates: 12/06/2000 - 12/06/2000 Issuance Date: 01/04/2001 `CSHOID: B7736 .1:1, 1e': .t. Optional Inspection Nbr: 01500 �- -- Citation and Notification of Penalt Company Name: Oak Park Heights, City of Inspection Site: 14168 Oak Park Blvd. No., Oak Park Heights, MN 55082-0007 Citation 1 Item 6 Type of Violation: Serious Minn. Rules 5206.0700 subp.2: The employer did not implement Right-to-Know training for employees who were routinely exposed to hazardous substances: ` The employer has not established RTK training for employees exposed to hazardous substances that would include but not be limited to gasoline,fuel oil, chlorine, fluorosilicic acid, SPANDS reagent for fluoride, insecticides, pesticides and herbicides. Abatement Guidelines: The employer must conduct initial and ongoing evaluations of the workplace determine the hazardous substances for which there is a reasonable potential for employee posure during the normal course of assigned work. A written Right-to-Know program must be developed and implemented which describes how the training, availability of information, and labeling requirements will be met. Employees must be provided with training in a manner which can be reasonably understood by them, and which addresses the required topics outlined in 5206.0700, Subpart 2. Training is to be provided at the cost of the employer. Records of training provided under this section must be maintained by the employer and retained for 3 years. The written Ri ht-to-Know ro ram shall include: 1) A description of how the training, availability of information, and labeling provisions will be met for the workplace as a whole or for individual work areas. 2) A list of the hazardous substances known to be present using an identity that is referenced on the appropriate material safety data sheet. A list of frequent tasks that expose employees to physical agents and method the employer will use to inform employees. The list may be compiled for the workplace as a whole or for individual work areas. See pages 1 through 3 of this Citation and Notification of Penalty for information on employer and employee rights and responsibilities. Citation and Notification of Penalty Page 8 of 10 MNOSHD-2(REV. 1/95) • • Minnesota Department of Labor Inspection Number: 303889026 Department tofand and Industry Inspection Dates: 12/06/2000 ' Safety Health Division - 12/06/2000 Issuance Date: 01/04/2001 �: '•Q4 11 CSHO ID: B7736 = :-- ; . Optional Inspection Nbr: 01500 `-.�'•:•_ - \i-- �r Citation and Notification ' '' of Penalt Company Name: Oak Park Heights, City of Inspection Site: 14168 Oak Park Blvd. No., Oak Park Heights, MN 55082-0007 3) The methods the employer will use to inform employees of the hazards of infrequent involve exposure to hazardous substances and the hazards associated with hazardous su sta that contained in unlabeled pipes in their work areas. bstances 4) Additionally, in multiemployer workplaces where the employer produces, uses substances in such a way that employees of other employers may be exposed, the written Ri andoo- Know program developed and implemented under Minn. Rules 5206. ub • 1 ght to 0700 Sub p (b) shall a) the methods the employer will use to provide the other employers with a copy material safety data sheet, or to make it available at a central location in the workplaf ce, for each hazardous substance the other employers' employees may be exposed to k while working; b) the methods the employer will use to inform the other employers on anyprecautionary P tionary measures that need to be taken to protect employees during normal operating conditions and in foreseeable emergencies; and c) the methods the employer will use to inform the other employers of the labeling system used in the workplace. The Ri'ht-to-Know trainin. .ro.ram for hazardous substances shall include: 1) the name or names of the substance including any generic or chemical name, trade commonly used name; name, and 2) the level, if any and if known, at which exposure to the substance has been res to standards adopted by the commissioner, or, if no standard has been adopted, acco dg o in 1 to guidelines established by competent professional groups which have conducted resear determine the hazardous properties of potentially hazardous substances; ch to 3) the known acute and chronic effects of exposure at hazardous levels, includingroutes 4) the known symptoms of the effects; of entry; 5) any potential for flammability, explosion, or reactivity of the substance; 6) appropriate emergency treatment; 7) the known proper conditions for use of and exposure to the substance; 8) procedures for cleanup of leaks and spills; 9) the name, phone number, and address of a manufacturer of the hazardous substance; and See pages 1 through 3 of this Citation and Notification of Penalty for information on employer and employee rights and responsibilities. Citation and Notification of Penalty Page 9 of 10 MNOSHD-2(REV. 1/95) • s Minnesota Department of LaborInspection Number: 303889026 Department Safety and Industry Inspection D12/06/2000 and Health Division Date: 01/042 - 12/06/2000 Issuance O1/04/2001 _ic.1-:$0‘..,,,;;W%y,,�1_ CSHOID: B7736 Optional I nspection Nbr: 01500 Citation and Notification of Penalt s?858 Company Name: Oak Park Heights, City of Inspection Site: 14168 Oak Park Blvd. No., Oak Park Heights, MN _ 55082 0007 10) a written copy of all of the above information which shall areas in which the hazardous substance is used or handled. be readily accessible in the Y area or Records of Ri ht-to-Know trainin shall include: Records of training must be maintained by the employer for three 1) the dates training was conducted; years, and at a m' 2) the name, title, and qualifications of the person who conducted ��' must include: 3) the names and job titles of employees who completed the training;the nd 4) a brief summarytraining; or outline of the information that was included in the training The followin. is the minimum re.uired Ire•uenc of trainin, • session. 1) before the initial assignment to a job where there is a reasonable potential for exposure during the course of assigned work, 2) prior to the time an employee may be exposed 3) training updates, to be provided no less than d to an additional hazardous substance s), and Y annually. ( reiinjKVVMMVR •.�.;.,+:{:r::.iiiiii•::is is y:iiiii:::?i:i.:i::iii:.i::: .th :! `ii' ':'re :' •.Y.::iiiiia iY.:ii�iii�i:i.:iY:iii::i:::::::::...... :ii:;.i:....:...:........1�tI. i:.iiiiiiii:�:.iiii:�' : :i.:.i..i...:. .:.::. : Gretchen B. Maglich Commissioner of the Department of Labor and Industry See Pages 1 through 3 of this Citation and Notification of Penalty for information on employer and employee rights and responsibilities. Citation and Notification of Penalty Page 10 of 10 MNOSHD-2(REV. 1/95) • S Minnesota Department of Labor and Industry Occupational Safety and Health Division IIiE 443 Lafayette Road �Uso =o� •.,• ;;,( :N n •CJ' St. Paul, MN 55155-4307 •sl Phone: (651)296-2116 FAX • (651) 297-2527 INVOICE Company Name: Oak Park Heights, City of Inspection Site: 14168 Oak Park Blvd. No., Oak Park Heights, MN 55082-2007 Mailing Address: 14168 Oak Park Blvd. No., Oak Park Heights, MN 55082-2007 Issuance Date: 01/04/2001 OSHI ID#: B7736 Optional Report No.: 01500 Summary of Penalties for Inspection Number 303889026 Citation 1, Serious = $ 1875.00 Penalty Payment- Payment of all penalties is to be made by check or money order payable to the order of Minnesota Department of Labor and Industry" and remitted with a copy of this invoice to the Occupational Safety and Health Division at the address above within 20 calendar days following receipt of this Citation. After 60 days, unpaid penalties shall increase 25 percent and shall accrue an additional interest of 10 percent per month compounded monthly until the fine is paid in full. • If any portion of this Citation and Notification of Penalty is contested, that portion of the penalty is not due and payable until the resolution of the contestation. However, .you are still obligated to pay the penalty on the uncontested portion of the citation within 20 calendar days following receipt of this Citation. NOTE: The penalties shown above have already been adjusted for Good Faith, Size and History credits. Page 1 of 1 CITY c* • '} OAK PARK HEIGHTS t" 14168 North 57th Street • P.O. Box 2007 • Oak Parl<Heights, MN 55082-2007 • Phone: . '4� 651/439-4439 • Fax: 651/439-0574 winmPost-IVM brand fax transmittal memoFrom 7671 ummiDecember 7,2000 iiiillf Mr.Bill Berndt Dept. Safety Inspector Fax# Occupational Safety and Health Division { 7� 7 Department of Labor and Industry 443 Lafayette Road N. St.Paul,MN 55155-4307 Re:Additional Information We received the files back from our consultant who was working on setting up safety programs for us, earlier this year. The MSDS book contains over 100 pages. I will attach the table of contents from the notebook and also the MSDS for the Hach Fluoride testing solution. The remainder of the MSDS's will be mailed tomorrow. Attached is the Confined Space Program. I will be adding specific information on our AIM Model 600 Four Gas Toxic Air Monitor, calibration procedures, etc, as well as information on our rescue equipment and permits for each of our sites. This program will be fairly easy to get back on track. We checked the circuits at Brekke Park and my afternoon/evening crew is working on replacing two of the wall plugs under the drinking fountain with blanks and adding GFI's going room. Jeff has readjusted the bench grinder and we are to the rest of the circuits in the oin to make an instructional sign showing the proper positioning of the guards. Also attached are the Form 200's for 1995 through today. Tom has requested that we send our hirst Reports of Injuries for these years. Since we are pushing to get these out by 4:30. I will mail the First Reports with the MSDS's. if you have any questions please call me. Sincerely; Jay `. ohnson PE Public Works Director Tree City U.S.A. Cit)Oak Park Heights • g MATERIAL SAFETY DATA SHEETS Table of Contents Data Sheet Description #of Pages 1. Pyro Chem ABC Multi-purpose Fire Extinguisher 2. Chlorine Gas(Hawkins Chemical) 2 3. Fluorosilicic Acid(DPC Industries,LCI Ltd) 12 4. Hach SPANDS Reagent for Fluoride 5 5. Hach DPD Free Chlorine Reagent Powder Pillows 1 6. Hach DPD Total Chlorine Reagent Powder Pillows 7 7. Ashland#2 Fuel Oil 7 8. Continental Research Bacto Dose 4 9. Continental Research Action 4 10. Wheeler Lumber Chromated Copper Arsenate (CCA)Pressure Treated Wood 1 11. Wheeler Lumber Wood Dust 7 12. Wheeler Lumber Creasote Treated Wood 7 13. Chemsearch Deo-Sect Insectiside 7 14. Round-Up Concentrated Weed and Grass Killer 3 15. Ortho Pruning Sealer 8 16. Ortho Weed-B-Gone Brush Killer 7 17. Brush-B-Gone Brush Killer 8 18. Ortho Hornet and Wasp Killer 8 19. Blue Waterbase Spray Paint(Seymour) 7 20. Green Waterbase Spray Paint(Seymour) 5 5 CAT. NO. 444 MATERIAL SAFETY DATA SHEET POS/: 48100 MSDS DATE: 6/13/97 For Assist Contact: HACH ORDER//: 330639 CHANGE NO.: 8745 Regula fairs Dept. HACH COMPANY Emergency Telephone 1/ PO Box 90 Ames, IA 50010 PO BOX 907 Rocky Mountain Poison Ctr. (800) 227-4224 AMES, IA 50010 (303) 623-5716 I. PRODUCT IDENTIFICATION PRODUCT NAME: SPADNS Reagent for Fluoride CAS NO.: NA CHEMICAL NAME: Not applicable FORMULA: Not applicable CHEMICAL FAMILY: Not applicable VII. FIRST AID MSDS NUMBER: M00481 II. INGREDIENTS EYE AND SKIN CONTACT: Immediately flush eyes and skin with water for 15 minutes. Remove contaminated clothing. Call physician. INGESTION: Do NOT induce vomiting. Give 1 - 2 glasses of water. Call a Hydrochloric Acid physician immediately. Never give anything by mouth to an unconscious PCT: <40 CAS NO.: 7647-01-0 SARA: NOT LISTED person. TLV: 5 ppm ceiling PEL: 5 ppm ceiling INHALATION: Remove to fresh air. Give artificial respiration if necessa HAZARD: Causes burns Call physician. Sodium Arsenite VIII. SPILL AND DISPOSAL PROCEDURES PCT: <0.1 CAS NO.: 7784-46-5 SARA: LISTED TLV: 0.2 mg/M3 as As PEL: 0.01 mg/M3 as As IN CASE OF SPILL OR RELEASE: Cover the contaminated surface with sodium IARC: LISTED NTP: LISTED bicarbonate or a soda ash-slaked lime mixture (50-50). Mix and add wa: HAZARD: Extremely toxic; cancer hazard if necessary to form a slurry. Scoop up slurry and wash the site with soda ash solution. The neutralized slurry may contain sufficient heavy Other components, each metal concentration to require landfilling or treatment at an EPA a PCT: <0.1 CAS NO.: NA SARA: NOT LISTED site. ppr` TLV: Not applicable PEL: Not applicable DISPOSE OF IN ACCORDANCE WITH ALL FEDERAL, STATE, AND LOCAL REGULATIONS. HAZARD: Not applicable IX. TRANSPORTATION DATA Deionized (Demineralized) Water PCT: to 100 CAS NO.: 7732-18-S SARA: NOT LISTED D.O.T. PROPER SHIPPING NAME: Hydrochloric Acid Solution TLV: Not applicable PEL: Not applicable HAZARD CLASS: 8 ID: UN1789 GROUP: II HAZARD: None I.C.A.O. PROPER SHIPPING NAME: Hydrochloric Acid Solution Any component of this mixture not specifically listed (eq. mother HAZARD CLASS: 8 ID: UN1789 GROUP: II components=) is not considered to present a carcinogen hazard. 4 III. PHYSICAL DATA I.M.O. PROPER SHIPPING NAME: Hydrochloric Acid Solution HAZARD CLASS: 8 ID: UN1789 GROUP: II STATE: liquid APPEARANCE: Dark red solution ODOR: Odorless X. REFERENCES SOLUBILITY IN: WATER: Miscible ACID: Miscible OTHER: Not determined BOILING POINT: 105=C MELTING PT.: NA SPEC GRAVITY: 1.015 pH: <0.5 1) TLV•s Threshold Limit Values and Biological Exposure Indices for 198E VAPOR PRESSURE: Not determined VAPOR DENSITY (air=1): ND 1989. American Conference of Governmental Industrial Hygienists, 198E EVAPORATION RATE: 0.64 METAL CORROSIVITY - ALUMINUM: Corrosive 2) Air Contaminants, Federal Register, Vol. 54, No. 12, Thursday, Januar STEEL: 0.207 in/yr STABILITY: Stable 19, 1989. pp. 2332-2983. STORAGE PRECAUTIONS: Store tightly closed. 3) In-house information 4) Technical judgment IV. FIRE, EXPLOSION HAZARD AND REACTIVITY DATA s) Outside testing. 6) NIOSH/OSHA Occupation.! Health Guidelines for Chemical Hazards. FLASH PT.: Not applicable METHOD: NA Cincinnati: Department of Health and Human Services, 1981. FLAMMABILITY LIMITS - LOWER: NA UPPER: NA SUSCEPTIBILITY TO SPONTANEOUS HEATING: None SARA: This product contains a chemical or chemicals subject to the report SHOCK SENSITIVITY: None AUTOIGNITION PT.: ND requirements of section 313 of Title III of the Sup Amendments an EXTINGUISHING MEDIA: dry chemical Reauthorization Act of 1986 and 40 CFR Part 372. FIRE/EXPLOSION HAZARDS: May emit toxic fumes HAZARDOUS DECOMP. PRODUCTS: Toxic fumes of arsenic and chlorides PER CALIFORNIA PROPOSITION 65: "WARNING - This product contains a chemica OXIDIZER: No NFPA Codes: Health: 3 Flammability: 0 Reactivity: 0 known to the State of California to cause cancer." CONDITIONS TO AVOID: Extreme heat or flames; contact with strong oxidizers, acids, active metals such as iron, aluminum or zinc and alkalies. V. HEALTH HAZARD DATA THIS PRODUCT MAY BE: corrosive to eyes, skin and respiratory tract. ACUTE TOXICITY: Oral rat LD50 540 mg/Kg = Moderately toxic ROUTES OF EXPOSURE: ingestion, inhalation TARGET ORGANS: Not determined CHRONIC TOXICITY: Not determined ROUTES OF EXPOSURE: Not determined TARGET ORGANS: Not determined CANCER INFORMATION: Not applicable ROUTES OF EXPOSURE: Not applicable TARGET ORGANS: Not applicable OVEREXPOSURE: Causes burns; if swallowed, causes sedation, twitching MEDICAL CONDITIONS AGGRAVATED BY EXPOSURE: Persons with impaired pulmonary function may be at Increased risk from fumes. VI. PRECAUTIONARY MEASURES Avoid contact with eyes, skin and clothing Do not breathe mist or vapor. Wash thoroughly after handling. PROTECTIVE EQUIPMENT: adequate ventilation, lab grade goggles, disposable latex gloves, lab coat THE INFORMATION CONTAINED HEREIN IS BASED ON DATA CONSIDERED TO BE ACCURATE. HOWEVER, NO WARRANTY IS EXPRESSED OR IMPLIED (C) MACH CO. 1999 REGARDING THE ACCURACY OF THESE DATA OR THE RESULTS TO BE OBTAINED FROM THE USE THEREOF. Hach Company, WORLD HEADQUARTERS, PO Box 389, Loveland, CO 80539 Hach Europe, OP 229, 85000 Namur 1, BELGIUM PAGE 1 OF 1 410 Confined Space Entry Policy and Program Responsible Officer Jay Johnson, Public Works Director Responsible Department Public Works Health and Safety Policy Purpose: The Confined Space Entry Policy and Program protects Oak Park Heights employees by assuring safe operating procedures when entering confined spaces such as silos, tanks, vats, vessels, boilers, sewers, pipelines, and vaults . Impact on Personnel and Operations: Any employee who must enter a confined space must follow these precautions . Governing Regulations: Minnesota Rule 5205 . 1040, 29 Code of Federal Regulations 1910 .146 — General Industry Minnesota Rule 5207 . 0930 - Construction Industry Program Components: Survey of potential confined spaces Evaluation and classification Establish entry procedure. Written operating and rescue procedures Responsibilities: Each department that has an employee who may enter a confined space during the course of work must create their own specific Confined Space Program using this procedure as a guide. All employees are responsible for following this program. Supervisors are responsible for training employees and ensuring compliance with this program. The Public works Department will review programs and provide technical support. Definitions: "Confined Space" is defined as a special configuration that could result in any of the following conditions : A. Atmospheric Hazard - the space contains the potential for dangerous air contamination, oxygen deficiency, or oxygen enrichment; or, B. Engulfment Hazard - contained material that could engulf an entrant; or, • 411 used to test Class lA confined spaces could be one type of monitoring equipment used. c) All instrumentation used for atmospheric monitoring in confined spaces must be maintained and calibrated according to manufacturers instructions . Calibration and routine types of maintenance (e .g. , sensor replacement) may be done by individual departments . Field maintenance procedures are explained in the instruction manual included with instruments . d) Records of calibrations and field tests must be maintained by the affected department for a minimum of one year. e) Calibration and field test information, including type of test required, testing schedule, and date tests were completed, shall be affixed to the instrument or be readily available at the time of use. f) During work in Class 1B and Class II confined spaces, each potential contaminant must be monitored continuously. Hazardous Concentrations of Some Contaminants Contaminant Alarm concentrations 02 (oxygen) <19. 5 % 02 (oxygen) >23 % CO2 (carbon monoxide) 35 ppm CO2 (carbon dioxide) 5000 ppm H2S (hydrogen sulfide) 10 ppm C12 (chlorine) 0 .5 ppm NO2 (nitrogen dioxide) 3 . 0 ppm NOX (oxides of nitrogen) 3 . 0 ppm CH4 (methane) >10 % lower explosive limit NH3 (ammonium) 25 ppm 03 (ozone) 0 . 1 ppm Flammable or combustible gas 10% lower explosive limit Particulate >10 % min. explosive concentration Notes: Use a triple gas instrument to measure toxic or flammable gas contaminant, 02 and LEL when the possibility of a hazardous atmosphere exists . Specialized operations may require special procedures . For example, when repairing tanks that have been filled with a flammable substances, specialized sampling and other safe operating procedures may be required. 6. Establish Worker Training Program • 410 a) Workers who will enter confined spacemust be the following: familiar with Nature of hazards present Signs, symptoms and consequences of overexposure Follow safe operating procedures Regularly communicate with the standby person Immediate exit when alarm, warning sign or other uncontrolled hazard begins b) Standby persons : Monitor each entrant visually or by voice Nature of hazards present Signs, symptoms and consequences of overexposure Use of needed rescue equipment To remain outside of confined space Prevent unauthorized entrance Signal alarms to entrants Summoning emergency responders c) Individuals whot perform atmospheric monitoring in confined spaces must review use of the equipment annually. d) Supervisors must know at least : Each of the items an entrant or standby person must know Verify that permit conditions are met Verify that necessary safe o eratin been selected and are used P g procedures have Terminate confined space Remove unauthorized individuals s when necessary 7. Develop a recordkeeping system a) Records of permits, be maintained at a training,centaand instrument calibration must on. b) Assign individuals with rspecific1responsibilit ' recordkeeping, ies for Appendix A: Examples of Confined Spaces and their at the Oak Park Heights Classification Appendix B: Example of Class II entry Appendix C: Example Confined Space EntryrmitPermitoFormre. Appendix D: Example Confined Space Entryy Permit Form - Class I Appendix E: Confined Space Entry Standard - Class II Date Revised III • Appendix A Examples of Confined Spaces and their Classification Category Description Hazard Contamin Location ants/gases Throughout OPH II Sewer manholes Oxygen deficient 02, H2S, atmosphere; dangerous CH4,NH3 air contamination; limited egress and entry. Throughout OPH II Storm sewer manholes Oxygen deficient 02 and pipes atmosphere; limited egress and entry 9th Ed., Beaudet, and IB Lift station,. Ventilated Oxygen deficient 02, H2S, Sunnyside Lift Stations control area atmosphere and NH3, CH4 Control Area(drywell) dangerous air with ventilation contamination operating 9th Ed., Beaudet, and II Lift station, Oxygen deficient 02,H2S, Sunnyside Lift Stations unventilated control atmosphere and NH3, CH4 Control Area(drywell) area dangerous air without ventilation contamination operating All Lift Station II Wetwells Oxygen deficient 02,H2S, atmosphere and NH3, CH4 dangerous air contamination Kern Center, Krueger IB Valve pits Oxygen deficient 02 Lift Stations, Towers atmosphere; limited 1&2, Pressure Reducing egress and entry Stations Throughout OPH IB Crawlspaces in homes Limited egress and entry 02 or businesses containing water meters NOTE: No confined space classification III has been noted where routine access by public works personnel are required. • Appendix B Confined Space Entry Procedures Example of Class II entry permit procedure. This permit is to be used for entry into a manhole for servicing or valve manipulations of water or sewer mains. The employee will follow the procedures for a Class II entry. This permit may not be used for a Class III entry. Meter readers will not enter Class III confined spaces. Only workers trained in confined space entry procedures within the past year may use this permit. 1. Confined space covers shall be removed and replaced, using tools designed for that purpose. Smoking and open flames shall not be permitted within twenty feet of the confined opening. 2. When removing or replacing confined space covers, care shall be exercised by workers to properly position their feet and hands so as to avoid back and extremity injuries. When opening such covers in the presence of snow or ice, the immediate area shall be salted or sanded to provide safe footing. A flame shall not be used to melt ice around a confined space cover. 3. It is necessary to ventilate all confined spaces before entry with a blower with a capacity of 1000 cfm or greater. The blower should be located to assure that engine exhaust gases are not blown into the confined space. Ventilate the confined space by blowing air into the space for at least 5 minutes before entering. The blowers should continue to operate while workers are in the confined space. 4. Tests shall be made before entering the confined space to determine the presence of an explosive atmosphere, oxygen deficiency, and toxic hydrogen sulfide with a multi gas toxic air monitor. Follow the manufacture's instructions to intialize the monitor and take a"zero"reading outside of the confined space and check the calibration record to betermine that the monitor has been calibrated within the previous 30 days. The "zero"readings display will show 00%LEL combustibles, 21.0%oxygen, and 00.0 ppm H2S. Pressing on the battery/dose position will display the time-weighted average in ppm H2S, as well as the elapsed time. The instrument is ready for use and no further preparatory action is required. To perform the initial monitoring, the meter shall be lowered to the bottom of the confined space using the extended cable and left there for a minimum of two minutes, and then withdrawn from the work space and any alarm indication observed. If no audible or visual alarm is operating, the work space is free of those gas hazards that the monitor is designed to measure. The monitor should have the following alarm settings: oxygen less than 19.5%deficiency, greater than 23%excess, toxic gas(hydrogen sulfide) ceiling limit greater than 20 ppm, • • TWA greater than 10 ppm, and combustible gas greater than 10%LEL of methane in air or equivalent. The results of this testing shall be recorded. If an audible or visual alarm is operating, entry into the confined space is not allowed. The toxic gas monitor must be field calibrated before use, or once per month, and the results of this testing shall be recorded on the calibration log for the instrument. The manufacture or representitive shall perform a calibration check on the meter at least once per year, or sooner if the meter does not pass the field calibration. 5. Before use, entry ladders shall be inspected to be sure they are safe. All tools and materials shall be handed down or lowered by handlines. 6. At least one of the workers entering the confined space shall be wearing the air monitor on their waist. If any workers in the confined space will be out of sight of the worker wearing the monitor,then these workers must also wear monitors. If the monitor alarm goes off while workers are in the confined space,the workers will immediately exit the confined space. Re-entry may occur following initial entry procedures. 7. Only approved low voltage (6 or 12 volt) light and extension cords, or electrical apparatus approved with a Ground Fault Circuit Interrupter, shall be used in confined spaces. 8. In the event of an emergency,the standby person may enter the confined space only after contactng the dispatcher with instructions to alert an emergency response team of their intention to enter the confined space. 9. This written permit will be retained for a minimum of 30 days. Permits shall be readily available to all workers before entering a confined space and the permits shall remain at the work site as long as the work is being performed there. Where atmospheric testing showed a dangerous air contamination, oxygen deficiency, or oxygen enrichment,the employer shall retain the written permit form for a minimum of one year. ID S Confined Space Entry Permit Oak Park Heights Public Works Class I Entry Only Class: IA IB Date: Expiration Date: Department: Job Description: Location: Precautions Taken: (Check one or more. ) 1. Ventilation/Blower used before entering. 2. Ventilation/Blower used continudusly while personnel in space 3. Continuous oxygen monitoring performed while personnel in space. 4. Emergency procedures reviewed. Atmospheric Testing: Atmosphere Testing Initial Reading Alarm* Continuous Yes No Monitoring Alarm Yes No Yes No ❑ ❑ Oxygen ❑ ❑ 0 0 ❑ ❑ Combustable 0 0 0 0 ❑ ❑ Toxic ❑ ❑ 0 0 *If alarm levels are reached, Class I permit is revoked. Description of the hazards known or reasonably expected to be present inthe confined space: Name(s) of person(s) assigned to enter: Qualified Tester: Hazards, Testing, Ventilation, and Emergency Procedures Have Been Reviewed. Supervisor Signature: M S Confined Space Entry Permit Oak Park Heights Public Works Class I Entry Only Class: IA IB Date: Expiration Date: Department: Job Description: Location: Precautions Taken: (Check one or more. ) 1. Ventilation/Blower used before entering. 2. Ventilation/Blower used continuously while personnel in space 3. Continuous oxygen monitoring performed while personnel in space. 4. Emergency procedures reviewed. Atmospheric Testing: Atmosphere Testing Initial Reading Alarm* Continuous Monitoring Alarm Yes No Yes No Yes No ❑ ❑ Oxygen ❑ ❑ ❑ ❑ ❑ ❑ Combustable ❑ ❑ ❑ ❑ ❑ ❑ Toxic ❑ ❑ ❑ ❑ *If alarm levels are reached, Class I permit is revoked. Description of the hazards known or reasonably expected to be present in the confined space: Name(s) of person(s) assigned to enter: Qualified Tester: Hazards, Testing, Ventilation, and Emergency Procedures Have Been Reviewed. Supervisor Signature: 4 S Confined Space Entry Permit Oak Park Heights Public Works Class II Entry Only Time Issued: Date: Time Expires: Job Description: Location: Name(s) of person(s) assigned to enter: Description of the hazards known or reasonably expected to be present in the confined space: Hazards that may be reasonably expected to be generated by activities in the confined space: Stand by Person(s) : Communications: ❑ Visual 0 Voice 0 Signal Line • S Atmosphere Testing Initial Reading Alarm* Continuous Monitoring Alarm Yes No Yes No Yes No ❑ ❑ Oxygen ❑ ❑ 0 0 ❑ 0 Combustable 0 0 0 0 ❑ ❑ Toxic ❑ ❑ ❑ ❑ * If yes explain procedures followed to correct the problem below: ❑ Communication procedures reviewed ❑ Worker(s) wearing monitor ❑ Emergency procedures reviewed ❑ SCBA for stanby person ❑ Five (5) minute escape capsule with employee entering ❑ Nearest telephone and/or 2-way radio location noted Authoring Person (Name and Position) Copy to Safety Coordinator • S Appendix E Training Fact Sheet Confined Space Entry Standard Occupational Safety and Health Administration (OSHA) Regulation: 29 CFR 1910.146 Who is covered: Confined Space Entry applies to all employees who are required to enter a space that has restricted entry or exit, and has a potential of accumulating dangerous gases or reduced oxygen levels. What training is required: The Confined Space Entry standard requires that all employees who enter restricted spaces receive training and information on the following topics: • Contents, location and availability of the Confined Space Entry Plan • Contents, location and availability of the department plan • Atmospheric conditions • Entry/Exit access • Engulfinent conditions • Confined Space Entry classification(Class I, IA, IB, Class II and Class III) • Determination of Confined Space Entry class • Specific Confined Space Entry procedures • Operating and Rescue procedures • Confined Space Entry permit forms and authorization • Test equipment procedure and calibration/maintenance schedule • When is training required: Employees must be trained prior to Confined Space Entry assignment initially and yearly thereafter. Recordkeeping requirements: Departments must establish and maintain records of employee training, confined space entry locations, testing of confined spaces and entry permits for at least five years. Contact name and number: For further information, call Jay Johnson,Public Safety Director at 651-439-4439 or e- mail:jiohnsonna cityofoakparkheights.com 41111• • • , • rt • `1.4 d '' k, s. d „,ar mj }� k as. t L °..:fs.4`` �?aCa. � i8'a: �� ' � r`eh' a •.S a�°•�;x�"K,",�ar�y �4 ,�, � � I s � f A°x`•,_ r ;•-ft» _n f'xs 7 x 1R City of Oak Park Heights 14168 Oak Park Blvd. Box 2007 Oak Park Heights,MN 55082 Phone(651)439-4439 Facsimile(651)439-0574 facsimile transmittal To: ;if i 6, IT- Fax: 65-7-)_,'? From: K lw. KG Date: ' I 71 7 O D • Re: !� / -1 0690 . ,iin7 Pages: eaQ CC: 0 Urgent 0 For Review 0 Please Comment 0 Please Reply 0 Please Recycle Notes: the_ 611°i/0114o Pc-'5i�Y� �, �I � ov, F''-s?- gef7c), ..2-,5k,ry s 119 S"— aou0da'r2. 11 ,f at( , ✓1 J vii Ns vt-' r 2 r epe/t q• 1. ' nt ;,, t00, ,�.."As�y' "k3e r a pvi�,ke.i?+✓sae �sv."� �{ �t,,,:. 4 •i 145 University Avenue West, St. Paul, MN 55103-2044 League of Minnesota Cities Fax: (651) 281-1297 • TDD (651) 281-1290 Cities promoting excellence September 14, 2000 Stanley Buckly 808 So. 2nd Street Stillwater,MN 55082 RE: Employer: Oak Park Heights Date of Injury: 4/4/00 Claim No: 2-729-911406-T4 Dear Mr. Buckly: This is to confirm that the Denial of your above captioned claim will not be rescinded. Following a thorough review of your medical records,it was determined that your condition is a result of several personal risk factors unrelated to your work activities. Sincerely, Patty Prentice Claim Examiner (651) 215-4171 AN EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER 28 Daae e9:54 0 TY OF OPH 41.11.MN 66166-430S ---r... • v■ n tJul v / P.02/02 im 2se•2472 See indoc strucne in folder ac 1 Adates must 9be; entered in MpanYtng forms. 1.OSHA.�I Type or Print. M/DONY format. !!II/JIIJJIjjIiijEMPLOYEE 2.Nam• a �II����I�I' 3.EMPLOYEE SOCIAL SECURE NO: II 14 4. Home add address nncludo a . ,,ecotarr., tlpl - S.DATE OF CLAIMED INJURY: Do Not Use Ulie Specs 7.Marital 8.OccupMarital Statin `Married ` - or 9.Date o/Dinh: Not 1j• �•ular0•• _ ��f�/,�.. 12. • y 10.Oats Mired;13.APPnlrltlee; _�/ � WAGE INFORMATI•N 14.Average wage/week16.Req par hour: o Yes 17.Data per week %© I .flours per day: [5.Whet le the weedy velum of MEALS: $ 19,Employment Stain: uU time pert If em to time �'-'�- LODGING: e P yee in a po0u officer or firefighter: _Seasonal _Volunteer(Attach '--��- 2nd INCOME ghter: Smoker Ye No_ 26 week wags statement �-� OCCURRENCE 20.PLACEler pantime or Irregularly �f ,N 4e)' (Meanie debt&tug eddmul 1./021,Date o/Ant day of loaf time: Li , �j 22. Dans employer - 1 ,I -it-°-� neon F o Yjtb III yl.. .d of injury: � , 23.Return ;._ • m to work data �f 3/� 24.Dare employer nodGed 6-1k--4C o/Fon time: •nem•to arse •r mho. 7 . r-7 /- - 27.DESCRIBE NA es Ii o Ar 4 26.Date of death: •r m,. 1rlJURYoRILWESSM � / 26.Timeo/day O,13iD DETAIL.0!SPECT/lC(,ny�o P•rrdl N bodyof injury: Mooted.•0•erolaatnn N�af+e Ingot Q F .�� • �N q 2r.d/sine.fractured arm,1••a oo(.anirol 20.DE$CII19E EMPLOY ', !~ �•.rdc•1•,rdlWan�unnatural ACTIVITIES wrlral UrJURY OCCURRED • ural mesons or e„�yrl ED NnTM DETAILS OP NOW EVENT OCCURRED :include name N r 'rl4 I aim L oel•r�ia•u•I.In"alvy eea4,machinery.o.i•eq woos. - s 1 29. PHYSIC! N (( am O e. eddraae and S /k• GIJA�, y f t'1"" '� Phone number, 30.HOSPITAUCLINIC(name and address)(ANL �, caste. r,p r l D ) .c . e lr. CS 1 I • S i/40 it'I. EMPLOYER 32. 31y OAK P mal name a mailing sddresa incl.zip 'L L �r// p PARK HEIGHTS ��• �0 3�� 14108 57TH STREET. 33.Date form completed: BOX 2007 /4/ 34.nomplo,ID No.: STILLWATER MN 5508E-0000 J 38.LPrint supenri.ore name and phone payroll Gass Code I. - ���+ � y 70.3 37.Employers Ae S•/tJl•� Dr•aanhtive,p/irrt full name,tido and Phone number. SEND REPORT IMMEDIATELY ••• •• - EMPLOY - 00 NOT WAIT FOR DOCTOR'S REPORT ER STOP MERE p0 NOT USE THIS SPACE NCONTAINS ALL)TENS P REQUIRED BY OSHA FORM I C s INSURANCE 38. CARRIER / T OCC Ci'' 39.Insurer lD No. SN/A do.ADJUSTER ELF- ' Berkley Administrator RED 41.InsuranceCl/all. Code: PP.O.OBox 59I43 42.CARRIER CLAIM NUMBER 0 "�' MPIS•r MN 55459-0143 43.Data inciter received r�2-:,�.. received notice: (612) 544-031 I LI-2°320-0611-021 Original to Berkley . 1• .. Adjuster ID No: 0698639002 Y Adminiatretoro • I Copies to Employer. Emnln,_..a . „ Minnesota Department of Labor and Industry • Workers'Compensation Division 443 Lafayette Road North First Report of Injury 1' Case# St.Paul,MN 55115-4305 (651)296-2432 See instructions on reverse side.T All dates must be entered in MM/DDS or print. Employee 2.Name(last,first,middle) m'format. ( 1�rt-) In ^ 3.EMPLOYEE SOCIAL SECURITY NO: F R O 1 4. Home address(include county a d zip) Inorcl L.f e, 4 LA" 1 Q > ) 5.DATE OF CLAIMED INJURY: �t'eC� 1 01 23 0 4 I Lilt i Syaal 1 r f 1 Do not use this space up�ti n 6.Sex. _ Male p Female Illic �% a 7.Marital Status: Married I& Lt)0 9.Date of Birth 0 Single 11• gular Dept.: 10.Date Hired: ��Q�� j-��C c � 1 12.Home Phone No.(A/C, No.) WAGE INFORMATION V t C W Q ( 13.Apprentice:® No❑Yes , 2 - � ,:s 14.Average wage/week 15.Rate per hours 0 A 3 16.Hours per day: 17.Days per week: ~ U 19.Employment Status: Full time18.What is the weekly value of MEALS: 19.empe) 0 Part timeM Seasonal o Volunteer(attach 26 week wage statement for part-time oLODGING: 2nd COe irregularly 9 y scheduled .� 20. PLACE include dept.&full address) 21. Date of first day V t C t",�Q R. S of any lost time: i9/�.3�0 22.Date employer notified of injury: t03(6 � et &� e___, 23.Return to work date: 24.Date employer notified of lost time: On employer's premises? 25.Date of death: 26.Time of day 27. Describe natureYes No 0 AM or inju .r illness in detail,be specific(include part(s)of body affected,e.g. of injury: (IVQt(' Si APM ^J 11�X • �P l t• 1�/-a r amputation fright index fing r at2n joint fractured i n i R d ex C t d1 (J+e-c in t r tt r( * gM� arm) 28.Describe employee's activities wheninjuryoccurredmachinery,objects, radiation, tions ofiemployee) 0 th r'l 411 e cv�a VY'(1-e VL (O r1•Q,.8, "�+''w r 2J( 29.Physician(full name,title,address and phone number P c O Q� ) 30.Hospital/Clinic(nameqand address) dress)i CG Ji Sin S f (4islsd >Il - crw ( (4 G /S� '1, 1/47_r_ t I.)8__S4)r) (A)IS , F" - L 31.Witness and phone number: EMPLOYER 32.Legal name&mailing address include.zip ( ) OAK PARK HEIGHTS 33.Date form completed: 34.Unemployment ID No.: PO BOX 2007 35.SIC code OAK PARK HEIGHTS,MN 55082-2007 36.Print supe1...7- name and phone number: Payroll class code -3-41e L Tv h n sr 37.Employer's Representative,print full name,title and phone number: SEND REPORT IMMEDIATELY-DO NOT WAIT FOR DOCTOR'S REPORT EMPLOYER STOP HERE-DO NOT USE THIS SPACE N P CONTAINS ALL ITEMS REQUIRED BY OSHA FORM 101 S T INSURANCE 38.Carrier(name,address&phone OCC number) 39.Insurer ID No.: ® Self-Insured 40.Adjuster name&address: League of Minnesota Cities Insurance Trust Berkley Risk Administrators 41. Insurer Class Code: Company, LLC 42.Carrier Claim Number 145 University Avenue West 02-000729 43.Date insurer received notice: St. Paul, MN 55103-2044 44.Adjuster ID No.: LI-20320-05(10/98)Original to Berkley Risk Administrators Com 0698639002 Pant,LLC.Copies to:Employer,Employee and workers'Compensation Division(if no insurer) LM 2510(8/99) minneaotauepartmentofLaborandIndustry Workers'Compensation Division First Report of Injury 443 Lafayette Road North St.Paul,MN 66166-4306 ee instructions in folder accompanying forms. SHA caw! 11111111 II'I'I liii 'll IIII 1812)258-2432 All dates must be entered in MM/DD/YY format. Type or Print. EMPLOYEE 2.Name (last,first,middle) 3.EMPLOYEE SOCIAL SECURITY NO: glsc-L-1 VA-V in k• Lfc,er P--ce-7/7 4.Home address (include county and zip) 5.DATE OF CLAIMED INJURY: iLW - 2S- dkn/ po �A��w^ ��f`�� Do Not Use this Space l me 7 `"'l- 4-coo ( 6. Sex: DCMaIe _Female 7. Marital Status: married Not B. Occupation: '9.Date of Birth: 06/-tCi_t2 FOl��e 0 G2 10.Date Hired: / 4r7-..2, _ 1 /- 1 1.Regular Dept: p 0 / 12.Homs Phone No. (A/C.No.) / 13.Apprentice: Ao Yes , WAGE INFORMATION 15.Rate per hour 16. Hours per da 14.Average wage/week -a!' i - - 17. Days per week: S 18.What is the weekly value of MEALS: t LODGING: 1 2nd INCOME: $ 19.Employment Status: 2Eull time _Part time _Seasonal _Volunteer(Attach 26 week wage statement for part time or irregularly scheduled employee.) If employee is a police officer or firefighter: Smoker: Yes_ No_ OCCURRENCE 20. P CE(include dept&full address) 21.Date of first �/ 22.Date employer 5-q0 ( old Q / y y(,Q` on( dsy of lost time:/(/ // notified of injury: t��/al! d U (( V L l �I(!r !! 23.Return to work date:/Y /_/_ 24. Date employer notified X..../ of lost time: / /_ 25.Date of death: /I/ / / 26.Time of day 0/QQ On employer's premises? �-1 of injury: o p 1 1_ Yes No 27.DESCRIBE NATURE OF INJURY OR ILLNESS,I DETAIL,BE SPECIF IC Occlude part(of body affected,e.g.amputation of N ht index finger at joint,fractured arm, oisoningl ed0 zed -114-u-y t Di S Gg body, cJCt,r f?9 'h�� i�i� -,. 7C L,-1- 28.DESCRIBE EMPLOYEE'S ACTIVITIES WHEN INJURY OCCURRED WITH DETAILS OF HOW EVEN OCCURRED (include name ofotherindividuals innvvv ved,tools,machinery,objects,vapors, chemicals,radiations,unnatural motions of employee) /®� _ /J /J ©�j -1��%'(4j(if-1iL.. /` 4/47 bile =10( ae a,-- acv( Ku-(�'-d . Aces -e& r9-4,1r9-4,1 / r 29. PHYSICIAN (full name,title, address and phone number) 30.HOSPITAL/CLINIC(name and address) Ne Pocfv2 Vt`;t-4- 6 &In oto • 44- ' Pt J` `Y• 31.Witness and phone number. EMPLOYER 32.Legal name&mailing address incl.zip �i /�O 34.Unemploy ID No.: OAK PARK HEIGHTS 33.Date form completed: If� 14168 57TH STREET, BOX 2007 35.SIC code Payroll Class Code STILLWATER MN 55082-0000 36. Print supervisor's name and phone number. 37.Employer's Representative,print full name,title and phone comber: L-(Nnal y Snub ©h 44-470-.3 SEND REPORT IMMEDIATELY - DO NOT WAIT FOR DOCTOR'S REPORT CONTAINS ALL ITEMS REQUIRED BY OSHA FORM 1C EMPLOYER STOP HERE-DO NOT USE THIS SPACE N P S T OCC INSURANCE 38.CARRIER 39. Insurer ID No: 40.ADJUSTER N/A Berkley Administrators SELF- INSURED 41. Insurance Class Code: P.o. Box 59143 Mpls., MN 55459-0143 (612) 544-0311 43.Date insurer received notice: 42. CARRIER CLAIM NUMBER 44.Adjuster 10 No: 0698639002 02 ;29 LI.20320-06(1-92) Original to Berkley Administrators • BA 251 $/I (4/92) Copies to Employer, Employee and Workers' Compensation Division Minnesota Department of Labor and Industry IIWorkers'Compensation Division 443 Lafayette Road North First Report of Injury 1 ` aseu St. N M Paul, 55115-4305 i ill III lin II (651) 32 See instructions on reverse side.Type or print All dates must be entered in MM/DD/YY format. Employee 2. Name(last,first,mi STS /ell/ 3. EMPLOYEE SOCIAL SECURITY NO: F R O 1 r -'4 4.Home addres in ude county and zip) +l,- , 9 O,^- 5. DATE OF CLAIMED INJURY: (]u � � �^ //� ..0,,e9 Do not use this space 8.Occupatio ! �`�ppb 6. Sex: ale 0 Female ❑ r 9.Dat- o Birth 7.Marital Status: ❑Married Single 11.Reg ar Dept.: ®r� i © '9.41 � 10.Date Hired: 12.Home Phone No.(A/0,No.) /17i S ( 13.13.Apprentice:0 No WAGE,%r" OR ATION /S" Ii- 5 ' O Yes 14.Avenge wage/week 15ji ate per hour: 7 16. Hours per day: 17. Days per week: / ` �,0" Employment Status:❑Full time18.What is the weekly value of MEALS: LODGING: 2nd19. pe) 0 Part time p Seasonal o Volunteer(attach 26 week wage statement for part-time orC 19. irregularlylscheduled em OCCURRENCE 20.PLACE(include dept.&full address) 21.Date of first day of any lost time: ! 22.Date employer ��14 „?",/i'notified of injuryj/j,/- 24.Date employer notified 7.), G;. 23.Return to work date: I,/ill d , s/>•.f lost time: art On employer's premises? 25.Date of death: 26.Time of day 27.Describe nature or injury or illness in detail,es 0 Noil,be specific(include P (s)of body af injury: !O c AM ffected,e.g.amputation of right index finger at 2nd joint,er A 0,forarm) / r.' ,, 28. Describe employee's activities when injury occurred with details of how event occurred(include na objects,vapors,chemicals,radiation, unnatural motions of employee) me of other individuals involved,tools,machinery, e- ,/' %./ . ,--- 29. Phsician(full name,title,addr,:.s and phone ,,i ber /n ! ,G. if -r 7 Z e� ) 30.Hospital/Clinic(name and address) Aliv, 31.Witness and phone number: EMPLOYER 32.Legal name&mailing address include.zip ( ) OAK PARK HEIGHTS 33. Dat- form clo 34. Unemployment ID No.: PO BOX 2007 35.S��,de plete• j/ OAK PARK HEIGHTS,MN 55082-2007 '11036.Print supervisor name an Payroll class code . GIS .pha er 37.Employers Representative,print full name,title and phone number. ( ) , (%�q53. SEND REPORT IMMEDIATELY-DO NOT WAIT FOR DOCTOR'S REPORT SPACE N PCONTAINS ALL ITEMS REQUIRED BY OSHA FORM 101 EMPLOYER STOP HERE-DO NOT USE THIS S INSURANCE T 38.Carrier(name,address&phone number) 39.Insurer ID No.: OCC ® Self-Insured 40.Adjuster name&address: League of Minnesota Cities Insurance Trust 41.Insurer Class Code: Berkley Administrators 42.Carrier Claim Number 145 University Avenue West 02-000729 43.Date insurer received notice: St. Paul, MN 55103-2044 44.Adjuster ID No.: LI-20320.06(5/96)Original to Berkley Administrators.Copies to:E 0698639002 Employer,Employee and Workers'Compensation Division(if no insurer) LM 2510(11/98) Workers'CompensationOivision First Report of Injury 443 Lal ayane Road North 11111 St.Paul,MN 66166 4306eeinstructions in folder accompanying forms. stiAc...i liii III liii (812)298-2432 All dates must be entered in MM/DD/YY format. 11111111 111111 Type or Print. `I EMPLOYEE 2.Name (last,first,middle) 3.EMPLOYEE SOCIAL SECURITY NO: D Krcp(Mow\k--.. 'ren �WWIES a3- 6,(0- yay6 0- 4. Home address(include county and zip) 5.DATE OF CLAIMED INJURY: a/G-7 +ter` � ��= 03 ci b-oo� Do Not Use this Space (,CL-CObu.3 01 f 5-cId. / 6.Sex: Male _Female 7. Marital Status: AMarried _Not 8.Occupation:r, �ro� 9.Date of Birth: 0'1 /i i/((> 10.Date Hired /CSI / �5 t 3 I"d1‘Ce, �mce v-- 11.Regular Dept 12.Home Phone No. (A/C,No.) O V- �' K t t ( Q( sh-k &ci? 30- .r&S9'l 13.Apprentice: No _Yes WAGE INFORMATION T 15.Rate per hour: 16. Hours per day: 14.Average wage/week 'Q179 , Hu a(p..S'/p 17. Days per week: C 18.What is the weekly value of MEALS: $ LODGING: $ '' 2nd INCOME: $ 19.Employment Status: lull time Part time _Seasonal Volunteer(Attach 26 week wage statement for part time or irregularly scheduled employee.) If employee is a police officer or firefighter: Smoker: Yes_ No) ' OCCURRENCE 20. PLACE(include dept&full address) 21.Date of first 22.Date employer VO"-VA-11 LCA. 1 0-it o day of lost time: A I / notified of injury: 4)3/•`r/ � Li r�C�r� ..--1- 24. Date employer notified 23.Return to work clan /A//_ WI^ a , Lo c r n� __ of lost time: / /_ l-� 25.Date of death: / / 26.Time of day a A' On employer's premises? 1 , Yes pr No for of injury: //00I'cc f )2r P' 27.DESCRIBE NATURE OF INJURY OR ILLNESS IN DETAIL,BE SPEWF IC(Include parts)of body affected,e.g.amputation of right index fines at 2nd joint,fractured arm,I.sd poisoning) 51Leil'--�-.. w.odc,k,z .6.,---g• G./, Iia..-d2 -- s.ia.e-f cc. fe "4t_7''' °T'i „iv.f Aa....„1 28.DESCRIBE EMPLOYEE'S ACTIVITIES WHEN INJURY OCCURRED WITH DETAILS OF HOW EVENT OCCURRED (include name of other, individuals involved. d.t000lsmachinery,objects,vapors, chemicals,radiations,unnatural metiorm of employee) ,......0...., t. _ pTo�.v^^ / d' /„...t.....„, e t Uk..Lc -Q- L.J tom►}y .-v1Pp X v' . v i r r U 29. PHYSICIAN (full name,title address and phone number) 30,.HOSPITAUCLINIC(name and address) 11111110111., Dr.63c k Lal KeUlcw m rv►t ..r,.JL fpr�� G Let-iceve'e rv�o- J I+ S 1 9e1 (.t) CA1%.)Y:.L.,I( W1 a c S O-- - tT't I t,-,--e-,-1 u ,S-p J _.g)- 31.Witness and phone number:!,S i- 455- 533 U (,).:,01)..<_,:-.)-61..44.s,),-.1-' L;i C- S I- (-(3O-/e51S- • EMPLOYER 32.Legal name&mailing address incl.zip "3 OG 34.Unemploy ID No.: OAK PARK HEIGHT5 33.Date form completed: J l J_ 14168 57TH STREET, BOR 2007 STILLWATER MN 55082-0000 35.SIC cods Payroll Class Code 36.Print supervisor's name and phone number: 37.Employer's Representative,print full name,title and phone number: Li/WY WN+>nt< cL C5(-y31- -/7l c ,.1NMI1�r3IA . ,-.1.y wtrriN 651- /3q-w37 SEND REPORT IMMEDIATELY - DO NOT WAIT FOR DOCTOR'S REPORT CONTAINS ALL ITEMS REQUIRED BY OSHA FORM 1C EMPLOYER STOP HERE-DO NOT USE THIS SPACE N P S T OCC INSURANCE 38.CARRIER 39.Insurer ID No: 40.ADJUSTER N/A Berkley Administrators SELF- INSURED MpI41.Insurance Class Cods: Box 59143 pls., MN 55459-0143 (612) 544-0311 43.Date insurer received notice: 42. CARRIER CLAIM NUMBER 44.Adjuster ID No: 0698639002 LI.20320•06(142) Original to Berkley Administrators - BA 251 S/I (4/92) Copies to Employer, Employee and Workers' Compensation Division Minnesota Department of Labor and Industry 1.OSHA Case# Workers'Compensation Division • First Report of Injury 443 Lafayette Road NorthII 11 I I 111 St.Paul,MN 55115-4305 See instructions on reverse side.Type or print. (651)296-2432 All dates must be entered in MM/DD/YY format. FRU1 Employee 2. Name(last,first,middle) 3. EMPLOYEE SOCIAL SECURITY NO: Hausken, Michael Sean 474-88-9892 4. Home address(include county and zip) 5. DATE OF CLAIMED INJURY: Cir) 905 Pine Tree Trail 07-26-99 Stillwater, MN 55082 Do not use this space Washington County 6.Sex {CMale 0 Female 7.Marital Status: Married 0 Single 8.Occupation: 9. Date of Birth 10. Date Hired: Police Officer 04-22-62 1-1-85 11. Regular Dept.: 12. Home Phone No. (A/C, No.) 13.Apprentice:R No❑Yes Police Dept. (657) 439-0126 WAGE INFORMATION 15.Rate per hour: 16. Hours per day: 14.Average wage/week $1173.00 $27.06 8 17. Days per week: 5 18.What is the weekly value of MEALS: 0 LODGING: 0 2nd INCOME: 0 19. Employment Status:IS Full time 0 Part time 0 Seasonal 0 Volunteer(attach 26 week wage statement for part-time or irregularly scheduled employee) OCCURRENCE 20.PLACE(include dept.&full address) 21.Date of first day 22.Date employer 15584 57th St. N. of any lost time: n/a notified of injury: 07-26-99 Oak Park Heights, MN 55082 24.Date employer notified 23.Return to work date: n/a of lost time: n/a 26.Time of day ft1 AM On employers premises? ❑Yes 0 No 25. Date of death: n/a of injury: 0005 0 PM 27. Describe nature or injury or illness in detail,be specific(include part(s)of body affected,e.g.amputation of right index finger at 2nd joint,fractured arm) Small cut on right thumb, exposed to other subjects blood. 28.Describe employee's activities when injury occurred with details of how event occurred(include name of other individuals involved,tools,machinery, objects,vapors,chemicals,radiation,unnatural motions of employee) Arresting suspect for assault. 29. Physician(full name,title,address and phone number) 30.Hospital/Clinic(name and address) Lakeview/Stillwater Medical Group 927 W. Churchill St Sti 11watPr All'? 31.Witness and phone number: ( ) (651) 439-7116 - Officer Geyen - Bayport Police EMPLOYER 32.Legal name&mailing address include.zip 34.Unemployment ID No.: OAK PARK HEIGHTS 33.Date form completed: 07-26-99 PO BOX 2007 35.SIC code Payroll class code OAK PARK HEIGHTS,MN 55082-2007 36. Print supervisor's name and phone number: 37. Employer's Representative,print full name,title and phone number: Tom Melena, Administrator, 651/439-4439 65D 439-4723 Chief Lindy Swanson ( ) SEND REPORT IMMEDIATELY-DO NOT WAIT FOR DOCTOR'S REPORT CONTAINS ALL ITEMS REQUIRED BY OSHA FORM 101 EMPLOYER STOP HERE-DO NOT USE THIS SPACE N P S T OCC INSURANCE 38.Carrier(name,address&phone number) 39.Insurer ID No.: 40.Adjuster name&address: Self-Insured Berkley Administrators League of Minnesota Cities Insurance Trust 41. Insurer Class Code: 145 University Avenue West St. Paul, MN 55103-2044 42.Carrier Claim Number 43.Date insurer received notice: 44.Adjuster ID No.: 02-000729 0698639002 LI-20320-05(5/96)Original to Berkley Administrators.Copies to:Employer,Employee and Workers'Compensation Division(if no insurer) LM 2510(11/98) First Report 443 La/assns Road North of St.Paul.MN 66166.4306 • See instructions in folder accompanying Injury 1612)tae-2432 panying fo - 1,OSHA Casa/ I 1111111 Tll dates must be entered in MM/DOY fo111111 Type or Print. 11111 III Ill I' EMPLOYEE 2. Name past first middle) f,t\ 3.EMPLOYEE SOCIAL SECURITY NO: 4.Home address include countyand zip) 152,p .()Q`v; -a/9�,� ied5.DATE OF CLAIMED INJURY; ���/j''/ / ®' Do Not Use this SPS H. Occupation: �t�W N 7.Marital Status: kMarried cp.�� Not ��`� �-� 9.Date of Birth: 4E-1.2?.../ 1 1,Regular Dept �G 10.Date Hired: ) f Q6- 12.Home Phone No.INC.No.) GS/ -L _[_ WAGE INFORMATION • O-..?r13.Apprentice; No Yes 14.Average wage/week 18. Hours per day: 17.Days per week:6"-' 18.What is the weekly value of MEALS: 19.Employment Status: F �_ LODGING: ice_ 2nd INCOME: __ ull time Part time _Seasonal _Volunteer(Attach 26 week wa If employee is a police officer or firefi hter: Smoker: Yes__ No_ 21. gs statement for part time or irregularly scheduled employe OCCURRENCE 20. PLACE(include dept&full address) ��� �X�2f7 ��� Ai_ of first day of lost time: 22. Date employer 4,44P �an'ie /61"-- , 1074/ .575-29,..2_ /5!r � notified of injury: L� p 23.Return to work date: / / notified of24.lostData time:employer noti / / On em.la er's .remises) 25.Date of death: / / 26. Time of day Yes � Na C 27.DESCRIBE NATURE OF INJURY OR ILLNESS IN DETAIL, P of injury: /�� /� ILfir IN D L,BE SPECIF IC(include arttsl of body affected,s.c.W talon of C Gf/r'/ 044 �, er S�� c 7 right index tinges at 2nd loirtt,fractured arm.Wed poisoning) 2B.DESCRIBE EMPLOYEE'S ACTIVITIES WHEN INJURY OCCURRED WITH DETAILS OF HOW EVENT OCCURRED lincluds name of other individuals involved, eMmieaia,rWiauans,umnural motion of amployas) /� S41.0:4,4 t A% A6. 0.--)r- . OF S l�!>✓f� Q•�T 1Lt tools,m. `�iects�r 29.PHYSICIAN (full name,tit address . and phone ) SDE L Z-E.1.)Senumber30.HOSPITAL/CLINIC(name and address) e,c kCt/4-4✓ )4/os,•'4(-, . 927 ch4, eche -$71GL4v.7'L.e �''f Ss-oR2 31.Witness and phone number: EMPLOYER 32. Legal name&mailing address incl.zip OAK PARK HEIGHTS issmini 1 ►163 �7)'(-jSTREET, g 33.Date form completed: E./�/ 9 9 34,Unemploy ID Na.: 2007 STILLFJATER MN .I.J+Ic32-{70(i;.1 Payroll Class Code 38. Print supervisor's name and phone rearnber i/o I. fer of Mme,- , r 7_ 37.Employer's Representative, Ge �"7;?1 G/3-9, L/' print full name,tiffs and phots number: SEND REPORT IMMEDIATELY - DO NOT WAIT FOR DOCTOR'S REPORT EMPLOYER STOP HERE-DO NOT USE THIS SPACE CONTAINS All ITEMS REQUIRED BY OSHA FORM N P S T OCC INSURANCE 38. CARRIER 39.Insurer ID No: 40.ADJUSTER _ N/A Berkley Administrators SELF- INSURED 4,• Insurance ClassCod .: P.O. Box 59143 Mpls., MN 55459-0143 43.Date insurer received notice: (6 12) 544-0311 44.Adjuster ID No: LI-20320-06 I1•e21 • Original to Berkley Administrators 0698639002 Copies to Employer, Employee and Workers' Compensation Division BA 251 S/I (4/92 443 Lafayette Road North••••an First St.Paul,MN 66I664306 • Report of Injury 1x121 MN 32 • See instructions in folder accompanyingform • All dates must be entered in MM/DD/YY form All d t Print. IlJJ 111111 EMPLOYEE 2.Name(Iakt first middle) 1111111 I" .69;"/�� �/ 3.EMPLOYEE SOCIAL SECURITY 4. Home address(include county and Z 7a-�/o zip) INJURY:/ /.5"-Se �� 5.DATE OF CLAIMED INJURY: LLl1CC�J Sri ,%�/� ( -5(%(/QQ • Do Net Use this Space,(/ Xli" //'1l1,/ - � 2�� 1.7.,/4-iC J iJ .Jt�So .. 8. Occupation: 7. Marital Status:xM ' i /'e (9{f�' c 9.Date of Birth; /4g_/2_3_/..C.5- p/ /aTed Not 11.Regular Dept: 10.Date Hired: /0/ yy �// ce 49-,,2 WAGE INFORMATION 13•Apprentice, 14. Average wage/week 15.Rats per hour Na Yes 4 9- 77• p n s '" 16. Hours per day: Rr 17.Days per week: ��CC / LJ 18.What is the weekly valve of MEALS: >t 19.Employment Status xF�time _part time - --- LODGING: $ If employee is a police officer or firefighter: Smoker Yea_ Volunteero -'�- 2nd INCOME $ (Attach 26 week wage statement for �_ OCCURRENCE PLACE(include dept&full pan time w irregularly scheduled employee Ll / 20. ° address) 21. Date of first /JCC3 377 5-74 /14./A. day of lost time: 22. Date employer // notified of injury J J 23.Return to work date: / / 24. Date em.player notlfied of lost time: On em.lo en's .remises? Yes No 25.Date of death: 26. Time of day Z7.DESCRIBE NATURE OF INJURY OR ILLNESS / IN DETAIL BE SPECIE IC fa�dude of injury: �q" nol Q.r / ^ Parris)of body affected,e.g.amputation ofex /015.0 ' C-12.'7 ^ 1^ /Il A.74 57 ye dT //.Oil A: ,r14/7 ,1 e0nt --finger at A.2n ,6 fractured arm.feed P )tett) /)u<7 0/' ar�i- _02yAirS. s�,9it lEsfl-C.A M a>l, i /nci� 28.DESCRIBE EMPLOYEE'S ACTIVITIES WH �^/6/9 c-4. chemicals.radiations. WHEN INJURY OCCURRED WITH ✓✓ unnatural A motion or employee) TH DETAILS OF HOW EVENT OCCURRED (include name of other �a�� di {�� Gl/als ///74", 4 a _/_ ay 7�// 'i S� ' individuals involved.tools,machinery.machinery.obje ts.vapors. GL's DL .ri��C,4 %, �1 /, b ,L /i1 �Ja� O! L� O`� /4/e O Z' T�rr',-) 0%9.+x- vvak.11, 29. PHYSICIAN (full name,title, address and phone numbed 30.HOSPITAUCLINIC(name and address) 31.Witness and phone number EMPLOYER 32.Legal name &mailing address incl.zip OAK PARK HEIGHTS 141 b3 ,�J TH33.Date form completed: ..7-Y47/217 34. Unemplay ID No.: STREET, BOX 2007 STILLWATER MN 550 82-0000 36. Print supervisor's name and phone number: Payroll Class Code 37.Employer's Representative,Print full name,title and phone number: SEND REPORT IMMEDIATELY - DO NOT WAIT FOR DOCTOR'S REPORT EMPLOYER STOP HERE-DO NOT USE THIS SPACE CONTAINS ALL ITEMS REQUIRED BY OSHA FORM N P S INSURANCE 38.CARRIER T OCC 39.Insurer 10 No: 40.ADJUSTER I w , ^ N/A Berkle S E L�- 'v v` Ry Administrators E D I"`ur'"CO Claes code; P, Box 59143 41. /Mpls., MN 55459-0143 42. CARRIER CLAIM NUMBER 43.Date insurer received notice; 1612 544-0311 44.Adjust 02-,:.,•.,..,729' Adjuster 10 No: 1.1-20320-0611-92) 0698639002 Original to Berkley Administrators BA 251 S/I (4/92) Copies to Employer, Employee and Workers' Compensation Division Workers'Comps/weber,Division First Report of Injury 443 laf'yene Road Nosh St.Pouf,MN 661664306 dinstructionsatesmustbe inentered in MM/Dfolder in MM/anyjngD/YY formformat.s. �A Ceara(e12)298-2432 11111111 IIIIII 111111111 11111 Type or Print. EMPLOYEE 2.Name (last,first.middle) 3.EMPLOYEE SOCIAL SECURITY NO: .Croft, Joseph Adam 471-88-0664 01(.17- ) 4. Home address (include county and zip) 5.DATE OF CLAIMED INJURY: 846 Lake Street 5-21-98 Do Not Use this Space St. Paul MN 55119 (Ramsey County) 6.Sex: gc_Male _Female 7. Marital Status: X Married Not 8.Occupation: 9.Date of Birth: / / Pnl i r' Clffi("Pr .111i2-1i_12210.Date Hired: 01 /O1 / 93 11.Regular Dept 12.Home Phone No.(A/C,No.) Oak Park Heights Police (612)439-4723 13.Apprentice: LNo Yes WAGE INFORMATION 15.Rate per hour: 16.Hours per day: 14.Average wage/week $23.90 8 17.Days per week: 5 18.What is the weekly value of MEALS: f LODGING: 8 2nd INCOME: 8 19.Employment Status: Full time _Part time _Seasonal _Volunteer(Attach 26 week wage statement for part time or irregularly scheduled employee.) If employee is a police officer or firefighter: Smoker: Yes_ Nom OCCURRENCE 20. PLACE(include dept&full address) 21.Date of first 22.Date employer day of lost time: / / notified of injury: 05t21/98 Stillwater Area High School _ 5701 Stillwater Blvd, 23.Return to work date: / / 24.Date employer notified Oak Park Heights MN 55082 or lost time: / / 26.Time of da '' l• 1� 25.Date of death: / / yJ` AM On employer's premises) 1 Yes I No °f t� 10: 59 0 Ph1 27.DESCRIBE NATURE OF INJURY OR ILLNESS IN DETAIL.BE SPEOF IC find da parts)of body affected,e.g.amputation of right index finger at 2nd joint,fractured arm,lead poisoning) Injury to right elbow (hyperextension), right wrist is slightly sore and small abrasion on right hand (top, between wrist and knuckles.) 28.DESCRIBE EMPLOYEE'S ACTIVITIES WHEN INJURY OCCURRED WITH DETAILS OF HOW EVENT OCCURRED linclude name of other individuals involved,tools,machinery,objects,vapors, chemicals,radiations,urxtatural motions of employee) I was on a traffic stop when the driver of the vehicle took off while my arm was in the drivers window. 29.PHYSICIAN (full name,title, address and phone number) 30.HOSPITAL/CLINIC (name and address) 31.Witness and phone number. Tom Simms (American Security) , SAHS 351-8040 EMPLOYER 32. Legal name&mailing address incl.zip �9g 7983042-000 34.Unemploy ID No.: OAK PARK HEIGHTS 33.Date form completed: .0.5L2 14168 57TH STREET, BOX 2007 35.SIC code Payroll Class Code STILLWATER MN 55082-0000 36. Print supervisor's name and phone number 37.Employer's Representative,print full name,title and phone number 612- Lindy Swanson 439-4723 Judy L. Hoist, Dep. Clk/Fin. Dir. 439-4439 SEND REPORT IMMEDIATELY - DO NOT WAIT FOR DOCTOR'S REPORT CONTAINS ALL ITEMS REQUIRED 8Y OSHA FORM 101 EMPLOYER STOP HERE-DO NOT USE THIS SPACE N P S T OCC INSURANCE 38.CARRIER 39.Insurer ID No: 40.ADJUSTER N/A Berkley Administrators sELF_ INsuREID a,•Insurance Class Code: P.o. Box 59143 Mpls., MN 55459-0143 (612) 544-0311 42. CARRIER CLAIM NUMBER 43.Date insurer received notice: 44.Adjuster ID No: 0698639002 02-00 0729 U-2O320-o6(t-ez) Original to Berkley Administrators • BA 251 S/I (4/92) Copies to Employer, Employee and Workers' Compensation Division Minnesota Department of Labor and Industry • First Report of Injury 1.OSHA Case*,Workers'Compensation Division 443 Lafayette Road North St.Paul,MN 55115-4305 See instructions on reverse side.Type or print. (812)296-2432 All dates must be entered in MM/DD/YY format. Employee 2. Name(last,first,middle) 3. EMPLOYEE SOCIAL SECURITY NO: F R O Kellogg , Jeff 469-72-2193 4. Home address(include county and zip) 5. DATE OF CLAIMED INJURY: 706 W. Elm St. 4-30-98 Stillwater, MN 55082 Do not use this space 6.Sex: Male 0 Female 8.Occupation: - 7.Marital Status:g)Married 0 Single 9.Date of Birth 10 Date Works 12-3-56 11.Regular Dept.: 12.Home Phone No.(A/C,No.) Public Works/Utilities 61 439-0550 13.Apprentice:IQNopYes '• ' WAGE INFORMATION 15.Rate per hour: 14.Avera a wage/week 16.Hours per day: 9 9 3, 381. 50/Mo. 19.51 8 17.Daweek: 5 ys p er 18.What is the weekly value of MEALS: LODGING: 2nd INCOME: -:19.Employment Status:El Full time 0 Part time 0 Seasonal ❑Volunteer(attach 26 week wage statement for part-time or irregularly scheduled :employee) OCCURRENCE 20.PLACE(include dept.&full address) 21.Date of first day 22.Date employer Public Works Dept. of any lost time: 5-1-98 notified of injury: 5-1-98 ', City of Oak Park Heights 24.Date employer notified 14168 57th S t. N. 23.Retum to work date: 5-1-98 of lost time: 5-1-98 P.O. Box 2007 26.Time of day IQ AM Oak Park Heights , MN No 55082 25.Date of death: of injury: 11:00 •to er's premises? 0 Yes ) ry: ❑ PM ' 0 'be nature or injury or illness in detail,be specific(include part(s)of body affected,e.g.amputation of right index finger at 2nd joint,fractured arm) 1 isted wrist - Dr. thought maybe tendonitis -be employee's activities when injury occurred with details of how event occurred(include name of other individuals involved,tools,machinery, vapors,chemicals, radiation, unnatural motions of employee) Jeff was tightening a sleeve on a watermain :,'tool slipped off the bolt and Jeff twisted his wrist. an(full name,title,address and phone number) 30.Hospital/Clinic(name and address) Balder Stillwater Medical Group PA 11water Medical Group PA 1500 Curve Crest Blvd. Stillwater, MN ',O Curve Crest Blvd. , Stillwatt Witness and hone number: 55082 ' 39-1234 MN 55082 613-439-2522 Roger Benson .T'YER 32. Legal name&mailing address include.zip 34.Unemployment ID No.: ' ' HEIGHTS 33.Date form completed: 5-5-98 7983942-000 •HEIGHTS,MN 55082-2007 35.SIC code Payroll class code rvisor's name and phone number: 37.Employer's Representative,print full name,title and phone number: e N319-I ]Jna Thomas M. Melena, Administrator (612-439-4439 PORT IMMEDIATELY-DO NOT WAIT FOR DOCTOR'S REPORT CONTAINS ALL ITEMS REQUIRED BY OSHA FORM 101 34. ' STOP HERE-DO NOT USE THIS SPACE P S T OCC 'T NCe 38.Carrier(name,address&phone number) 39.Insurer ID No.: 40.Adjuster name&address: Workers' Comp. Assigned Risk Plan '� •989s1000 Berkley Administrators 41. Insurer Class Code: PO Box 59143 nsured - Im NumberMinneapolis, MN 55459-0143 43.Date insurer received notice: 44.Adjuster ID No.: 0698639002 Ms)OWNi,I to Berkley Administrators.Copies to:Employer,Employee and Workers'Compensation Division(if no insurer) BA2510 (6/96) ",-,- o..ul1-a0orandIndustry Workers compensation Division Ai First Report of Injury 1.OSHA Casae 443 Lafayette Road North St Paul,MN 55115-4305 All atesumctions on reverse ust be entered sMM/D orf print(812)298-2432 • Employee 2. Name(last,first,middle) 3. EMPLOYEE SOCIAL SECURITY NO: F R O1 Benson Roger G. 470-34-4435 4.Home address(include county and zip) C11`61\ 5. DATE OF CLAIMED INJURY: 9154 Fairy Falls Rd, Stillwater, MN 55082 4-1-98 Washington County Do not use this space 6.Sex: Male❑Female 7.Marital Status: (Married 0 Single 8.Occupation: 9• Date ofBirth 10. Date Hired: Public Works Director • 11. Regular Dept.: Public Works 12.Home Phone No.(A/C,No.) 614 439-2522 13.Apprentice: Of No❑Yes WAGE INFORMATION 15.Rate per hour: 14.Average wage/week 836. 99 20 .92 16.Hours per day: 8 1 17. Days per week: 5 1 18.What is the weekly value of MEALS: LODGING: 2nd INCOME: 19.Employment Status:in Full time 0 Part time 0 Seasonal ❑Volunteer(attach 26 week wage statement for part-time or irregularly scheduled employee) OCCURRENCE 20.PLACE(include dept.&full address) 21.Date of first day 22.Date employer City of Oak Park Heights of any lost time: 4-1-98 notified of injury: 4-1-98 Public Works Department 24.Date employer notified 14168 57th S t, N. 23.Return to work date: 4-2-98 of lost time: 4-1-98 Oak Park Heights , MN 55082 26.Time of day AM On employer's premises? 0 Yes ( No 25.Date of death: of injury: 9":40 ❑ PM 27.Describe nature or injury or illness in detail,be specific(include part(s)of body affected,e.g.amputation of right index finger at 2nd joint,fractured arm) Cracked bone in left wrist. 28.Describe employee's activities when injuryoccurred with details of how event occurred(include name of other individuals involved,tools,machinery, objects,Dvapors,chemicals,radiation,unnatural motions of employee) Employee was attempting to remove a sewer manhole cover using a cover tool. The tool slipped causing him to fall backwards on to the street. 29.Physician(full name,title,address and phone number) 30.Hospital/Clinic(name and address) Stillwater Medical Grou Stillwater Medical Group 1500 Curve Crest Blvd. p 1500 Curve Crest Blvd. , Stillwater, MN 5508: (61)2-439-1234 31.Witness an phone_121 mbar. EMPLOYER 32.Legal name&mailing address include,zip 013-439-6121 Jeff Johnson & Nick Ch ave s 34.Unemployment ID No.: OAK PARK HEIGHTS 33.Date form completed: PO BOX 2007 4-2-98 7983042-000 OAK PARK HEIGHTS,MN 55082-2007 35.SIC code Payroll class code 36.Print supervisor's name and phone number: 37.Employer's Representative,print full name,title and phone number: ( ) Thomas H. Melena City Administrator SEND REPORT IMMEDIATELY-DO NOT WAIT FOR DOCTOR'S REPORT-619 CONTAINS AU.ITEMS REQUIRED BY OSHA FORM 101 EMPLOYER STOP HERE-DO NOT USE THIS SPACE N P S T OCC INSURANCE 38.Carrier(name,address&phone number) 39.Insurer ID No.: 40.Adjuster name&address: ID MN Workers' Comp.Assigned Risk Plan ID#9999961000 Berkley Administrators 41.Insurer Class Code: PO Box 59143 CO Self-Insured 42.Carrier Claim Number Minneapolis, MN 55459-0143 02-000729 43.Date insurer received notice: 44.Adjuster ID No.: 0698639002 1I-20320.05(5/95)Original to Berkley Administrators.Copies to:Employer,Employee and Wortcers'Compensation Division(if no insurer) BA2510 (6/96) workers'Compensation Division�• eauy 443 Lafayette Road North First Report of Injury OSHA case4 i St.Paul,MN 55115-4305 (612)296-2432 We instructions on reverse side.Type or pnnt. • 11111111111 All dates must be entered in MM/DD/YY format. E '�Oye@ 2. Name(last,first,middle) 3. EMPLOYEE SOCIAL SECURITY NO: F R O 1 Kellogg, Jeff P. 4. Home address(include county and zip) 469-72-2193 17_1 5. DATE OF CLAIMED INJURY: 706 W. Elm St. Stillwater, MN 55082 7-31-97 Do not use this space 8. Occupation: 6. Sex:23 Male p Female Public Works/Parks Maintenance 9. Date of Birth 7.Marital Status: Married 0 Single 11.Regular Dept.: 10. Date Hired: 12-3-56 9-6-77 12.Home Phone No. (A/C,No.) WAGE INFORMATION 612 439-0550 13.Apprentice: [ No 0 Yes 14.Average wage/week 735 . 6 0 15.Rate per hour: 16. Hours per day: 18.39 8 17.Days per week: 5 M-F 18.What is the weekly value of MEALS: LODGING: 19. Employment Status:El Full time 0 Part time ❑Seasonal ❑Volunteer(attach 26 week wage statement for part-time or irregularlyscheduled employee) 2nd INCOME: OCCURRENCE 20.PLACE(include dept.&full address) 21.Date of first day 60th St . , Oak Park Heights22.Date employer Public Works/Water Dept. of any lost time: notified of injury: 8-1-9 7 City of Oak Park Heights 24. Date employer notified 23.Return to work date: P.O.kkBo x 2007 of lost time: OnUemplo Parkr mises Heights„tp�e r 0 N55082 25.Date of death: 26.Time of day El AM 27.Describe nature or injury or illness in detail,be specific(include part(s)of body affected;e.g.amputation of right of finger ato2njoint, PM Injury to lower back. fraduredarm) 28.Describe employee's activities when injury occurred with details of how event occurred(include name of other individuals involved,tools,machinery, objects,vapors,chemicals,radiation,unnatural motions of employee) Employee was raising water valve boxes on 60th St . He was bent over the extensions on. Later in dayhe found he could not stand upstraight, - . - _ i twisting 29.Physician(full name,title,address and phone number) -wl l 30.Hospital/Clinic(name and address) ( ) 31.Witness and phone number: EMPLOYER 32.Legal name&mailing address include.zip ( ) 34. Unemployment ID No.: OAK PARK HEIGHTS 33.Date form completed: Po BOX 2007 8-1-97 7983042-000 OAK PARK HEIGHTS,MN 55082-2007 35.SIC code 36,print supervisor's name and phone number: Payroll class code t Oger enson37.Emplo et's Representative,print full name,title and phone number: 6l 439-4439 MichaelyRobertson, Administrator SEND REPORT IMMEDIATELY-DO NOT WAIT FOR DOCTOR'S• 2 REPORT-44 • EMPLOYER STOP HERE-DO NOT USE THIS SPACE CONTAINS ALLITEMS REQUIRED BY OSHA FORM 101 N P S T OCC INSURANCE 38.Carrier(name,address&phone number) 39.Insurer ID No.: 40.Adjuster name&address: ❑ MN Workers' Comp.Assigned Risk Plan ID#9999961000 Berkley Administrators ® Self-Insured 41.Insurer Class Code: PO Box 59143 42.Carrier Claim Number Minneapolis, MN 55459-0143 ,?6,-C, 43.Date insurer received notice: 44.Ad ( �•�.•?,,_/� ju star ID No.: 02-000729 3 C LI-20320-05(5/96) G! 0698639002 Original to Berkley Administrators.Copies to:Employer,Employee and Workers'Compensation Division(if no insurer) BA2510(6/96) 443 Lafayette Road Northma[on First Report of Injury St.Paul,MN 66166.4306 letzl 299-2432 in folder accompanying forms. Type•tructions s must be entered in MM/DD/YY format. +1>t ea** or Print. s. IIIIIJIIilIiIIIIIIIiiijijj EMPLOYEE 2.Name pt,fiasrst,middle► I"I ANDERSON3.EMPLOYEE SOCIAL SECURITY NO: KENNETH RAY 4.Home address(include co470-96-1003 1508 DRIVING P andip► Gl ' 5.DATE OF CLAIMED INJURY: 12-15-96 STILLWATER, MN 55082 WASHINGTON COUNTY Do Not Use this Space 8. Occupation: 7. Marital Status: POLICE OFFICER XMarried Not 9.Date of Birth: 2/11 / 66 1 1.Regular Dept 10.Date Hired: 1 1 / 90 POLICE DEPT ! 12.Home Phone No. (A/C,No.) WAGE INFORMATION 612-430- 8213.Apprentice: No Yes I14.Average wage/week I l 15.Rate per ho l � 1. � 16.Hours per day: 17. Days par week 18.What is the weekly value of 8 5 y MEALS: _ 19.Employment Status: XFW)time pan timeonal - LODGING: $ If employee is a police officer or firefighter: Smoker: Yes No Xteer(Attach 26 week wage -- 2nd INCOME: t statement for �_ 1 OCCURRENCE 20. PLACE(include dept&full address) pan time orlRegularly scheduled employee.) PARKING LOT OF SUP 21.Date of first I ER 8 MOTEL day of lost time: 12 /(S/Cii 22• Date employer notified of injury: 12 /15 /96 23.Return to work date: / / 24.Oats employer notified of lost time: On em.Io er's .remises? 25.Date of death: / / • Yes �' No / / 26.Time of day 27.DESCRIBE NATURE OF INJURY OR ILLNESS IN DETAIL,BE SPECIFIC(include part(a)of body affected,e a AM ASSISTED STILLWATER OFFICER IN TRYING TO of injury; 0250 HEADa amputation of right index finger joint, ❑ PM ASST BY FLASHLIHE OF T SUBDUE SUSPECT. DURING STR STRUCKGLEEWASdarm.lead eoINl STILLWATER OFFICER. HEAD CONTUSION AND LACERATION. IN the scats, ad EMPLOYEE'S ACTIVITIES WHEN INJURY OCCURRED WITH DETAILS OF 28.DESCRIBE IBEiEMPL YEE'S al motionE of employes) I S.A.A. HOW EVENT OCCURRED (include name of other individuals involved,toot,machinery,objects.vapor, 29. PHYSICIAN (full name,title,address and phone number) • 30,HOSPITAUCLINIC(name and address) MICHAEL POTTER, LAKEVIEW HOSPITAL 927 W CHURCHILL, STILLWATER 439-5330 LAKEVIEW HOSPITAL 31.Witness and phone number STILLWATER OFFICER ALLEN, 439-1314 EMPLOYER 32. Legal name&mails OAK PARK, mailing address incl,zip HEIGHTS 33.Date form completed: 12/ 1 9. 34.unemploy ID No.: 14168 57TH STREET, BOX 2007 STILLWATER MN 55082-0000 36. Print supervisor's name and phone number:.q3 -y 7 Z .1,1te.5. LI N• �` . �v� 3 37.Employer's Representative,print full name,title and phone num' �.JW Al - number: SEND REPORT IMMEDIATELY - DO NOT WAIT FOR DOCTOR'S REPORT ` • ` ,. � _ t/93? EMPLOYER STOP HERE-DO NOT USE THIS SPACECONTAINS ALL ITEMS REQUIRED BY OSHA FORM 101 N P S INSURANCE 38.CARRIER T OCC 39.Insurer ID No: 40.ADJUSTER N/A Berkley y Administrators 41. Insurance Class Code: P.O. Box 59143 I Mpls., MN 55459-0143 42. CARRIER CLAIM NUMBER 43. Date insurer received notice: (612) 544-0311 02-r.}r, 0 29 44.Adjuster ID No: Ll-20320-o6(1-e2l0698639002 Original to Berkley Administrators ' BA 251 S/I (4/92) Copies to Employer, Employee and Workers' Compensation Division Waikato'Como.,,..eonDivuion _ irs 'apo o injury x__,.›. II1lII I'I'I ILII SII I"I • 11111111 Paul,MN.Road North structions in folder accompanying forms. jSt.6 2(298-2432 66166-4306 '• •OS must be entered in MM/DD/YY format. Ie 121 Type or Print. EMPLOYEE 2.Name (last•first,middle) 3.EMPLOYEE SOCIAL SECURITY NO: clb 3 ANDERSON, KENNETH RAY 470-96-103 4. Home address(include county and zip) 5.DATE OF CLAIMED INJURY: 1508 DRIVING PARK RD Do Not use this Space STILLWATER, MN 55082 WASHINGTON CO 10-26-96 6.Sex: v-Mals Female 7. Marital Status: X Married Not 9.Date of Birth: 2 / 11/ 66 10.Date Hired: 1 / 1 / 9O 8.Occupation: POLICE OFFICER 12.Home Phone No.jA/C,No.) 1 g,Apprentice: _No Yes 11.Regular Dept OAK PARK HEIGHTS POLICE DEPT 6612. 430-2823 15.Rate per hour: 16.Hours per day: 8 �I WAGE INFOe/week 1 9 Zq-.- z 1 ,z-}9 14.Average wage/week 0/h� LODGING: $ 2nd INCOME: $ CI 17.Days per week: 5 118.What is the weekly value of MEALS: i V 19.Employment Status: .,Full time _Part time _Seasonal _Volunteer(Attach 26 week wage statement for part time or irregularly scheduled employee.) If employee is a police officer or firefighter: Smoker: Yes_ No X of first 22.Date employer � q OCCURRENCE 20.PLACE(include dept&full addressl 21.Date notified of injury: 1n/-'6 day of lost time: ��_ FRESTAURA::T PARKING LOT 0 MCDONALDS 24. Date employer notified 23.Return to work date: /_!_ of lost time: _/ / I 26.Time of day 2313 AM 25.Date of death: // of injury: /.i'��PM �-I Yes No _ 27 employer's premises? I I amputation rimy at 2nd 27.DESCRIBE NATURE OF INJURY OR ILLNESS IN DETAIL.BE SPEF IC(induds partlslc f bb Aody�Ec t.d.s4.N vTHKNE S nde%IAMPraED RIGHT fractured poisoning) ng)SORE SCRAPE ON LEFT ELBOW, SCRAPE ON LEFT HAND, RIGHT ELBOW AND SHOULDER n v V ONE SU .Enol �'L D b.,t7 28.DESCRIBE EMPLOYEE'S ACTIVITIES WHEN INJURY OCCURRED WITH OEfAtlS OF HOW EVENT OCCURRED fnclud;name of ether individuals imdwd,tools,machine ole acts vapor an.mic,l.,r.ei.tiTne,um.Turr PURSUING fHNI'1 IN '.`1CD0 IALL'SFLCT, FELL AANLBLA::DEDTON�AVEME T IN LOT FOOT, WHILE 29. PHYSICIAN (full name,title,address and phone numbed 30.HOSPITAL/CLINIC(name and address) p1\ , -.4. ,``- �.WI UiL�W w . LAI4E-Uielw q2-7 w -C\ ,tli S�llw � .C.K I4 c-�t`t -T!-22j S Witness and phone number. Cl Z'-j l/s v 31. ,-- EMPLOYER 32.Legal name&mailing address in10-27-96 34.Unemploy ID Na.incl.zip 33.Date form completed: // OAK PARK HEIGHTS Payroll Class Code 14168 57TH STREET, BOX 2007 35.SIC code 5508 2-0000 STILL41r•.TEft MN .,.� 8� 36.Print supervisor's name and phone number. 37.Employer's Representative,print full name,tide and phone number. CHIEF LINDY SWANSON 439-4723 IM1d,nAEC_ Vkbel2-k 'Anrni. .--- 447)9-yq SEND REPORT IMMEDIATELY - DO NOT WAIT FOR DOCTOR'S REPORT CONTAINS ALL ITEMS REQUIRED BY OSHA FORM 101 EMPLOYER STOP HERE-DO NOT USE THIS SPACE S T OCC N. P 39.Insurer ID No: 40.ADJUSTER INSURANCE 38.CARRIER N/A Berkley Administrators P.O. Box 59143 41.Insurance Clast fie= SELF-INSURED Mpls., MN 55459-0143 (612) 544-0311 43.Date insurer received notice: 44.Adjustor ID No: 42.CARRIER CLAIM NUMBER 0698639002 02-000729 BA 251 SII (4/92) LI.20320-06(1-921 Original to Berkley Administrators Copies to Employer, Employee and Workers' Compensation Division Minnesota Department of Labor and Industry Workers'Compensation Division First Report of Injury 443 Lafayette Road North St.Paul,MN 66766-4306 nstructions in folder accompanying forms. �Me• 11111111111111111 18121 298-2432 All dates must be entered in MM/DD/YY format. Type or Print. EMPLOYEE 2. Name (last,first,middle) 3.EMPLOYEE SOCIAL SECURITY NO: HAUSKEN, MICHAEL SEAN 474-88-9892 4. Home address(include county and zip) 5.DATE OF CLAIMED INJURY: 905 PINETREE TRL 8-17-96 Do Not Use this Space STILLWATER MN 6.Sex:X Male _Female 7. Marital Status: ,-Married _Not 8. Occupation: POLICE OFFICER 9.Date of Birth: La_ l_�J�j� 10.Date Hired: 1 / 1 / 85 11.Regular Dept POLICE DEPT CITY OAK PARK HEICIHSHome Phone No.(ANC,No.) 612 439-0126 13.Apprentice: No Yes - WAGE INFORMATION 15.Rate per hour. 16. Hours per day: 14.Average wage/week 17. Days per week: 5 18.What is the weekly value of MEALS: $ LODGING: $ 2nd INCOME: $ 19.Employment Status: XFuil time _Part time _Seasonal _Volunteer(Attach 26 week wage statement for part time or irregularly scheduled employee.) If employee is a police officer or firefighter: Smoker: Yes_ No_ OCCURRENCE 20. PLACE(include dept&full address) 21.Date of first 22.Date employer CITY HALL OUT SIDE POLICE GARAGE DOORS day of lost time: / / notified of injury: / /_ 23.Return to work date: 24.Date employer notified of lost time: / / 25.Date of death: / / 26.Time of day 0 AM �1 L I --- of injury: 0 PM On employer's premises? 1111 Yes I--I No 27.DESCRIBE NATURE OF INJURY OR ILLNESS IN DETAIL.BE SPECIF IC(include parts)of body affected,e.g.amputation of right index finger at 2nd joint,fractured arm,teed poisoning) STUNG BY WASP ON THE INSIDE OF THE RIGHT BICEP HAD AN ALLERGIC REACTION TO THE STING. ARM SWOLLEN DN RED AND SORE FROM STING. 28.DESCRIBE EMPLOYEE'S ACTIVITIES WHEN INJURY OCCURRED WITH DETAILS OF HOW EVENT OCCURRED (include name of other individuals involved,tools,machinery,objects,vapors, chemicals,radiations,unnatural motions of employee) HAD PUT STRAY CAT INTO POLICE GARAGE AND WAS LEAVING GARAGE WHEN STUNG NEST ABOVE DOOR. 29.PHYSICIAN (full name,title,address and phone number) 30.HOSPITAL/CLINIC(name and address) STILLWATER MEDICAL GROUP DR TIM BALDER STILLWATER MEDICAL GROUP 31.Witness and phone number. EMPLOYER 32.Legal name&mailing address incl.zip a 17 96 34•Unemploy ID No.: OAK PARK HEIGHTS 33.Date form completed: / / 14168 57TH STREET, BOX 2007 35.SIC code Payroll Class Code STILLWATER MN 55082-0000 36. Print supervisor's name and phone number. 37.Employer's Representative,print full name,title and phone number: CHIEF LINDY SWANSON 439-4723 SEND REPORT IMMEDIATELY - DO NOT WAIT FOR DOCTOR'S REPORT CONTAINS ALL ITEMS REQUIRED BY OSHA FORM 101 EMPLOYER STOP HERE-DO NOT USE THIS SPACE N P S T OCC INSURANCE 38.CARRIER 39.Insurer ID No: 40.ADJUSTER N/A Berkley Administrators SELF- INSURED 41.Insurance Class Cods: P.O. Box 59143 Mpls., MN 55459-0143 (612) 544-0311 43.Date insurer received notice: 42.CARRIER CLAIM NUMBER 44.Adjuster ID No: 0698639002 02-0 0729 LI.20320-05(1-82) Original to Berkley Administrators • BA 251 S/I (4/92) Copies to Employer, Employee and Workers' Compensation Division WokersCompensationOivwon First Keport OT Injury S . Northe Road North Se • ctions in folder accompanying forms. 1.OSHA 11111111 II'I'I 11111111111 St.t.Paulaul,MN 65166-4306161 21 296.2432 F must be entered in MM/DDIYY format. Tyr.. or Print. EMPLOYEE 2.Name(lastfirst,middle) 3.EMPLOYEE SOCIAL SECURITY NO: HAUSKEN, MICHAEL SEAN 474-88-9892 CI() -, 4.Home address(include county and zip) 5.DATE OF CLAIMED INJURY: 905 PINETREE TRAIL 4-4-96 Do Not Use this Space STILLWATER MN 55082 WASHINGTON ) 6.Sex: Mala _Female 7.Marital Status: X Married Not B. Occupation: POLICE OFFCIER 9.Date of Birth: 4/22 / 62 10.Date Hired: ],_/ 1 / _ 11.Regular Dept POLICE DEPT OAK PARK HEIGHS 12.ftipme Phone No.(A/C,No.) 13.Apprentice: XNo Yes (pi2- Li 39 - 0t 210 WAGE INFORMATION 15.Rate per hour. 16.Hours per day: 14.Average wage/week 40 $21. +R 17.Days per week: 5 18.What is the weekly value of MEALS: 8 0 LODGING: $ 6 2nd INCOME: $ C 19.Employment Status:,/Foil time Part time Seasonal Volunteer(Attach 26 week wage statement for part time or irregularly scheduled employee.) If employee is a police officer or firefighter: Smoker: Yes_ NoX OCCURRENCE 20. PLACE(include dept&full address) 21.Date of first 22.Date employer ON OLDFIELD AV AT THE CORNER OF 60th ST N day of lost time: / /_ notified of injury: __H/ S/ % OAK PARK HEIGHTS MN. . 24.Date employer notified 23.Return to work date: 1 l_ of lost time: / 1 • 25.Date of death: _/ / 26.Time of day p AM t--� �I of injury: Z k 2'S PM On employer's premises? 1 f Yes 1�l No 27.DESCRIBE NATURE OF INJURY OR ILLNESS IN DETAIL BE SPECS IC(Include partial of body affected.s.4.amputation of rigM index finer at 2nd joint.frectursd arm,led poisoning) STRAIN LOWER BACK WHEN FIGHTING TO CONTROL PARTY. FELT PAIN IN BACK THEN NUMBNESS IN RIGHT LEG. 28.DESCRIBE EMPLOYEE'S ACTIVITIES WHEN INJURY OCCURRED WITH OETAILS OF HOW EVENT OCCURRED (include name of otter individuals involved.tools.machinery,objects,vapors, chsndulsl radiations.umswnr motions of employee) HAD A PARTY UNDER ARREST INSQUAD CAR HAD TO STOP CAR AT ABOVE LOC. AND RESTRANIN PARTY FURTHER THEN HANDCUFFS. SHE WAS PLACED ON GROUND AND THEN PICKED BACK UP. OFFICER HOPPE PRESENT AND PARTY MELISSA MAXEY. . . 29.PHYSICIAN(full name,title, address and phone number) 30.HOSPITAUCLINIC(name and address) STILLWATER MEDICAL GROUP STILLWATER MN 55-82 DR TIM BALDER 31.Witness and phone number. OFFICER PAUL HOPPE 439-4723 EMPLOYER 32.Legal name&mailing address incl.zip 34.Unemploy ID No.: OAK PARK HEIGHTS 33.Date form completed: 4 / 4 / 96 14168 57TH STREET, BOX 2007 STILLWATER MN 55082 35.SIC code Payroll Class Code 36.Print supervisor's name and phone number: 37.Employer's Representative,print full name.title and phone number CHIEF LINDY SWANSON 439-4723 Mr. Michael Robertson, City Admin. , 439-4439 SEND REPORT IMMEDIATELY - DO NOT WAIT FOR DOCTOR'S REPORT CONTAINS ALL ITEMS REQUIRED BY OSHA FORM 101 EMPLOYER STOP HERE-DO NOT USE THIS SPACE N P S T OCC INSURANCE 38.CARRIER 39.Insurer ID No: 40.ADJUSTER N/A Berkley Administrators SELF-I N S tJ R E D MpI 41.Insurance Clan Cad. P.O. Box 59143 Mpls., MN 55459-0143 (612) 544-0311 43.Date insurer received notice: 42.CARRIER CLAIM NUMBER 02-000729 44. AdJUfSer 1O No: 0698639002 LI-20320-06(1.92) Original to Berkley Administrators BA 251 S/I (4/92) Copies to Employer, Employee and Workers' Compensation Division St.Paul.MN 88168-4306See' trUCtjons in folder accompanying forms, I.OSHA Casal tat 2)298-2432 All must be entered in MM/00/YY format. 11111111111111 1111!liiiPrint. III 111! EMPLOYEE 2.Name past,first.middle) 3.EMPLOYEE SOCIAL SECURITY NO: Hausken Michael Sean 4.Home address (Include 474-88-9892 county and zip) 5. DATE OF CLAIMED INJURY: 905 Pine Tree Trail Washington- County 08/12/95 Stillwater, MN 55082 • Do Not u..titi.sp,�e 8. Occupation 7. Marital Status: _Married Not Police Officer 9.Date of Birth: Qq/ / 11•Regular Dept: 10.Date Hired: 01 / 01/ 85 Police Deet, 12.Home Phone No. (A/C,No.) WAGE INFORMATION •1 '- 13.Apprentice: ' j Q 4/ �L-NO _Yes 14.Average wage/Week "+' (J 7 6� 15.Rate per hour: 1�I l q 16.Hours per day 17.Days per week: / 18.What is the weekly valve of �--� d l O I MEALS: !-�_ LOGGING: ! 19.Employment Status; 'Full time �_ 2nd INCOME $_ 1 If employee Part time _Seasonal _Volunteer(Attach 26 week wags statement for part time or P yee is a police officer or firefighter, Smoker: Yes No_ -_ irregularly scheduled employee.) I OCCURRENCE 20. PLACE(Include dept&h41 address) 21.D.te of first 15112 N. 62nd St. day of Lost time: Nyjr‘ I22.Date employer Park Heights, MN / notified ofinjury: .0_8114_1_9_5. I 55082 23.Return to work date,N� / 24,Date employer notified/ silt} / I�' of lost time; On em.lo er's •remises? 11 Yes 25.Oats of death: 1Y/� / / 26.Time of day 27.DESCRIBE NATURE OF INJURY OR ILLNESS IN DETAIL. No 0145 $ AM of injury; All.BE SPECIE IC Grtetuds pin(*)of body effected.e.g. PM anwutatien o!right index finder at 2nd faire,fractured areas,lead peiaarrrpl Lower back strain on injured disk. I 28.OESCAIBE EMPLOYEE'S A T)VME WHENINJURY OCCURRED Will DETAILS OF HOW EVENT OCCURRED (include nam of other individuate invalwd,tools.machinery,objects,aspen,chemicals,radiation..unnaturalmeto of employee/ attempting to arrest subject, subject resisted initiating 29. PHYSICIAN (fullPhone name,title, address and a struggle. number) 30.HOSPITAUCLINIC(name and address) 31.Witness and phone nurnber: EMPLOYER 32. Legal name&mailing address incl,zip �AK PARK HEIGHTS 14168 57TH STREET33.Gate form completed: 08//14/95 34.Unemploy ID No.: STILLWATER ' BOX 2007 MN 550822 1111112111111111111111 36.Print supervisor's name and phone number- Lindy Swanson 37.Employer's Representative,print full name,title and phone num 612-439-4723 Michael Robertson Administrator 612-43 - SEND REPORT IMMEDIATELY - DO NOT WAIT FOR DOCTOR'S REPORT CONTAINS ALL ITEMS RE 9 4439 EMPLOYER STOP HERE-DO NOT USE THIS SPACE N P REQUIRED BY OSHA FORM 101 S T OCC INSURANCE 38-CARRIER 39.Insurer ID No: 40.ADJUSTER N/A Berkley Administrators SELF-INSURED P.O. Box 59143 Mpls., MN 55459-0143 42•CARRIER CLAIM NUMBER 43.Data insurer roes (612) 544-0311 02-000729 received notice: 44.Adjuster 10 No: I LI.20220.06 It-s2l Original to Berkley Administrators 0698639002 BA 251 S/I (4/92) Copies to Employer, Employee and Workers' Compensation Division CITY CAD • OAK PARK HEIGHTS 14168 North 57th Street • P.O. Box 2007 • Oak Park Heights, MN 55082-2007 • Phone 651/439-4439 • Fax 651/439-0574 r4 Post-ItrM brand fax transmittal memo 7671 #of pages ► f December 7,2000 To ; ��^( I} ( -I From ��i Jo- 11 �o h/0 s on ?} co. /44 co. 01 ra r 14'1' Dept. Phone# Mr.Bill Berndt Safety Inspector Fax# Fax# Occupational Safety and Health Division Department of Labor and Industry 443 Lafayette Road N. St.Paul,MN 55155-4307 Re:Additional Information Per our conversation I have faxed the MSDS's as well as the First Reports of Injuries rather than mailing them as indicated in the earlier letter. I will be looking for training records tomorrow. Rollie my utility worker went to the League of Minnesota Cities 2000 Safety and Loss Control Workshop this last spring. Both Jeff and Rollie went to water school this year which usually includes safety classes. If you have any questions please call me. Sincerely; Jay E. Johnson,PE Public Works Director Tree City U.S.A. CITY 04, III OAK PARR HEIGHTS - 14168 North 57th Street • P.O. Box 2007 • Oak Park Heights, MN 55082-2007 • Phone:651/439-4439 ' •s? Fax 651/439 0574 Post-Ir brand fax transmittal memo 7671 I#of pages ► 3 i December 8,2000 To QQ�. f From Q• i lkh Jiily Tial*vocal, Co. Mr.Bill Berndt Dept. - fiphvdt Tl A f !r iii,*j Safety Inspector Fax# Occupational Safety and Health Division Fa #3 y 3 Department of Labor and Industry 443 Lafayette Road N. St.Paul,MN 55155-4307 Re:Additional Information This afternoon I was looking through the material from our former consultant and found a floppy disc with a bunch of files on them which will help us with writing the programs. Much of it is pretty good. We need to make some changes and fill in some blanks. The enforcement policy needs to comply with our three union contracts and the information on the health clinics we want to use need to be filled in. I have only done a quick review and will be doing a detailed review in the next week or so. The attached are printouts based on the disc I found. Sincerely; rr Sy ohnson,PE Public Works Director Tree City U.S.A. • City of Oak Park Heights Safety Program SAFETY POLICY STATEMENT The City of Oak Park Heights' Safety Program is based on the premise that each and every one of our employees are entitled to a safe and healthful working environment. Our Safety Program is designed specifically for the protection of our employees and visitors. Management,Department Heads and all employees are directed to make safety and loss control important matters. We believe that every employee is concerned for their own safety and that of their co-workers and will recognize that the rules and policies contained herein are for their protection. The goals that we have set for our Safety Program can only be achieved through a cooperative effort between all employees along with management. Safe working habits and an awareness through knowledge of all safety rules and policies are a condition of your employment at the City of Oak Park Heights. All employees are required to familiarize themselves with every rule and policy set forth and to abide by them. These rules and policies will be enforced just as any other city policy and failure to comply can result in reprimand, suspension,or employment termination. All employees are encouraged to make suggestions which will assist in maintaining safe working conditions, and to bring to the attention of their supervisor any unsafe working conditions. It is through our joint participation that accidents can be prevented, but only you,the individual, can make safe work practices a habit. Accidents cause pain and suffering,waste time and money,and can cost someone their life The City of Oak Park Heights is committed to providing you with a safe place in which to work. We require your assistance and participation in keeping it that way. We will never ask you to commit an unsafe act or violate a safety rule,therefore,we expect the same from you. Our policy toward safety is no way limited to the rules that follow and any unsafe practices,whether listed here or not,will be addressed. • City of Oak Park Heights Safety Program SAFETY GOALS AND OBJECTIVES The City of Oak Park Heights is committed to providing its employees with a safe and healthy work environment. To achieve this environment the city has set forth goals and objectives to be met and tactics by which they will be accomplished. GOALS: 1. A year by year reduction in employee accidents and injuries until they stand at or near zero. 2. Help develop safe work habits and attitudes among employees. 3. Provide a channel of communication between workers and management. OBJECTIVES: 1. To establish a Safety Program that will reduce the number of injuries and accidents to a minimum,not merely keeping with, but surpassing,the best experience of other operations similar to ours. 2. To reduce workers'compensation Experience Modification by 10%over the next 2 - years. TACTICS: 1. To quarterly review past injuries for trends by types and causes of accidents, shifts, repeaters, etc. 2. Annual review of the safety program to meet the current safety needs of the City. 3. To provide supervisors and employees with safety training. S S City of Oak Park Heights Safety Program MANAGEMENT SAFETY RESPONSIBILITIES 1. Appoint a Safety Coordinator with the authority to maintain the program on a day to day basis. 2. Allocate sufficient time and resources to effectively implement the safety program. 3. Assign safety responsibilities and hold people accountable for these duties. 4. Actively promote safety program. 5. Interview employees for suggestions and opinions. 6. Provide to all employees a copy of the Safety Policy and Safety Program. 7. Provide initial and continuing training programs. 8. Actively monitor the activities, progress and results of the Program by: a. Periodic reviews with the Safety Coordinator. b. Periodic reviews of accident reports and related information. c. Attending, when possible, scheduled safety meetings and training sessions. 9. Give positive recognition to those employees who consistently perform their duties in a safe manner. 10. Leading by example. 11. Administer job site safety inspections and take action on hazards after consulting with the safety manager and/or management. 12. Coordinate job-site safety meetings which address specific job related hazards as well as general safety policies. 13. Oversee training in the proper operation of tools and equipment for all employees. 14. Must contact the office and complete appropriate forms immediately following any injury. 15. Must post local emergency numbers at each location. Is also responsible for ensuring that a first-aid kit and material safety data sheet(MSDS) book are present at each location. 0 • City of Oak Park Heights Safety Program EMPLOYEE SAFETY RESPONSIBILITIES 1. Learn the hazards of assigned job or jobs and the appropriate safety measures to these hazards. eliminate or lessen 2. Become familiar with and observe all city policies and safety rules. 3. Report all observed hazards affecting themselves and others to supervisor or safety 4. Report all incidents, including all accidents and job related injuries involving coordinator. employees, and the public. themselves, other 5. Use personal protection equipment as required. 6. Seek assistance or information if in doubt as to how to safely perform an assigned 7. Exercise due care when usingcityg d task. property and equipment, and use it only for authorized purposes. 8. Report known acts of theft or vandalism. 9. Submit recommendations for safety and efficiency to the Safety Coordinator as 10. Comprehend information on material safety data sheets. necessary. 11. Know where the emergency exists are located. 12. Know the evacuation plan from the building in case of fire or other emergencies. 13. Know where fire extinguishers are located. g 14. Use only grounded electrical outlets and report any ungrounded electrical outlets. 15. Attend safety meetings and safety training as directed. 16. Request ergonomically proper equipment and personally adjust equipment to and other repetitive motion injuries. P avoid carpal tunnel 17. Pay attention to good housekeeping: -Do not block entrances or stairways - Use proper lighting -Provide adequate ventilation -Remove any tripping hazards. 18. Use proper lifting procedures. • • City of Oak Park Heights Safety Program SAFETY COORDINATOR RESPONSIBILITIES 1. Professional Development >Coordinate all safety activities, including working with outside sources such as insurance personnel. >Establish minimum safety standards, rules, and regulations in consultation with management. >Establish and maintain a health and safety reference library. >Keep apprised of changes in health and safety regulations. >Participate in professional organizations related to occupational health and safety. 2. Program Development and Administration >Develop and maintain the written injury and illness prevention program. >Assemble and communicate loss and safety information to supervisors and management. >Assure that all first report of accidents are processed and submitted to State, Federal agencies and the insurance carrier. >Set-up and maintain vehicle and driver files. >Assure that safety equipment is available and that storage locations are clearly designated. >Develop and maintain injury and illness prevention policies and procedures to include: safety rules, incentive and motivation programs, accident investigations, safety inspections. >Plan and prepare for natural and "man-made" disasters. >Establish a medical program which includes on-site first aid capabilities and off-site emergency medical care. >Formulate, amend and administer all city safety policies. >Ensure that the city complies with all OSHA, federal, state and local regulations. >Coordinate city safety meetings and periodically supervises job site safety inspections. >Schedule meetings with each supervisor to discuss possible safety policy improvements. 3. Training and Communication >Coordinate a general safety orientation for all new employees. >Develop training programs for both new and veteran employees. >Ensure that employees comprehend information on material safety data sheets (MSDS). >Chair the Labor/Management Safety Committee. >Train managers and supervisors in their safety responsibilities. >Accompany outside safety inspectors and consultants on tours of the facilities. >Follow up on recommendations generated by outside safety inspectors and consultants. >Determine the need for surveys by specialists, such as fire protection engineers, industrial hygienists, and ergonomists. >Explain the city safety policy to management, supervisors and employees assuring that all employees and supervisors are aware of and comply with requirements for safe practices and conditions to be maintained in all work areas. >Develop technical guidance and interim programs to identify and remove physical hazards from work sites. >Update all levels of management on matters pertaining to safety such as decisions involving work-site • City of Oak Park Heights Safety Program hazards. >Provide Superintendents/Foremen with the appropriate material for conducting weekly "tool box" safety meetings. Periodically attend "tool box" safety meetings to evaluate effectiveness. 4. Internal Consultant >Work with personnel to assure safe placement and job assignment. >Communicate regularly with management to keep them informed of progress, problems and needs. >Determine if safe practices and conditions are being maintained by conducting inspections of work places and equipment and by interviews with employees. >Ensure that the city attains and maintains compliance with known federal and state standards in regards to work place safety. >Conduct hazard analysis of facilities and operations. >Work with Engineering on special hazards. >Study hazards of planned and proposed facilities and operations. >Conduct a thorough investigation of those accidents where specialized knowledge is required. >Conduct research on technical safety problems. 5. Information Management >Maintain the accident recordkeeping system. >Maintain an accident file and review all accident reports. Personally investigate those accidents where necessary to determine what occurred and what steps need to be taken to avoid a recurrence. >Review and respond to employee suggestions relative to improving work place safety. >Maintain documentation on all aspects of the injury and illness prevention program. >Be responsible for the timely filing of accident reports and related data with insurance companies and regulatory agencies. >Maintain an adequate accident report system, personally investigate serious accidents and take corrective action to eliminate accident causes. Also prepare and distribute to all department heads regular reports on accidents. >Periodically conduct safety inspections (announced and unannounced) of the work areas and take necessary corrective actions to eliminate all unsafe acts and/or conditions. >Conduct a thorough investigation of all accidents, whether they are injury related or property damage/loss. >Communicate with the insurer and OSHA. 6. Measuring Performance and Results >Audit supervisory safety performance, middle and upper management safety performance and company safety performance. SAFETY AND HEALTH COMMITTEE RESPONSIBILITIES 1. Purpose • i City of Oak Park Heights Safety Program To help in the detection and elimination of unsafe conditions and work procedures, a safety and health committee will be established with representation from employees and management. 2. Procedure >The following guidelines will be followed: >Employees shall select fellow workers to represent them on the committee. >The terms of employee-elected members shall be a maximum of two years. Should a vacancy occur on the committee, a new member shall be elected. Terms should be staggered to provide continuity. >The frequency of meetings shall be determined by the safety and health coordinator. >The date, hour, and location of meetings shall be determined by the safety and health coordinator. >The length of each meeting shall not exceed one hour except by majority vote of the safety and health committee. >The attendance and subjects discussed shall be documented and maintained on file for a period of five years. Copies of the minutes must be provided to: • top management • the safety officer, and • employees, by posting on the bulletin board and in break areas. 3. Scope of Activities >Conduct in-house safety inspections. >Assist in accident investigation to uncover trends. >Review accident reports to determine effectiveness of controls. >Accept and evaluate employee suggestions. >Review job procedures and recommend improvements. >Monitor the safety program effectiveness. >Promote and publicize safety. • • City of Oak Park Heights Safety Program DRIVER SAFETY RESPONSIBILITIES The city considers the safety of our employees,and the protection of others and their property, to be a main concern. To assure this safety and protection in all areas of operation, a Driver Safety Policy has been developed which is as follows: Driver Safety: 1. Wear a seat belt whenever the vehicle is in motion. 2. Obey all traffic laws at all times. 3. Always be courteous to other drivers. 4. Keep your vehicle neat and clean at all times. 5. Never leave the keys in an unattended vehicle. 6. Check the engine oil weekly, add if necessary. 7. Change the engine oil and lubricate the vehicle every 3,000 miles. Give documentation of this work to the supervisor. 8. Check tire pressure weekly. 9. Report any mechanical problem as soon as it is discovered. 10. All tools and materials shall be secured to prevent movement. 11. All incidents involving personal injury of employees or others,damage to company property or others,and situations involving potential hazards,must be reported to the Safety Coordinator immediately. 12. Vehicle accidents should be reported immediately from the accident scene if possible. 13. All drivers must maintain a Minnesota drivers license. 14. Procedures In Event Of An Accident: Any driver involved in an accident must obtain the following information at the scene of the accident: A. The names and addresses of the other driver(s),passengers(s),and witness(es). B. The owners name of the other vehicle(s) involved, if it is other than those named above. C. License numbers of all vehicles involved. i i City of Oak Park Heights Safety Program D. The name of the insurance company,and policy number, of each vehicle involved. E. A diagram of the accident. F. Each city vehicle shall have an"emergency packet"which has the necessary forms to record the above information. If possible,these forms should be filled out at the scene of the accident. G. The Safety Coordinator should be informed of the accident as soon as possible. 15. Evaluation of Drivers: A questionable driver: A. One"at fault"accident in the latest two-year period. B. Three moving violations in the latest three-year period. C. Any driver who has a past driving record, regardless of time period, that indicates unsafe or irresponsible driving habits. An unacceptable driver: A. Two"at fault"accidents in the latest two-year period. B. Four moving violations in the latest three-year period. C. Any combination of"at fault"accidents and moving violations totaling four or more. D. One "operating a motor vehicle under the influence" in the latest five-year period. 16. Motor Vehicle Record Checks A. A motor vehicle record check will be conducted annually on all drivers of city vehicles. B. All job applicants under consideration for employment will have a motor vehicle record check if they will be driving a city vehicle in their job. If their driving record does not meet city standards, they will not be allowed to drive a city vehicle or they will not be hired. 411 • City of Oak Park Heights Safety Program HAZARD CONTROL POLICY IDENTIFICATION,ANALYSIS,AND CONTROL OF WORKPLACE HAZARDS A. Workplace hazards will be identified through a periodic review of accident records,first reports of injury,OSHA 200 logs,safety inspections,and employee suggestions. B. A survey of work areas will be made to identify routing hazards that could be encountered by employees.A hazard list will be developed.This list will identify work areas or activity,hazards,and controls for the hazards.This list will not be inclusive of all hazards and must be updated on a regular basis.In addition,Job Hazard Analysis could be performed on those jobs which present high hazard, high frequency of accidents or high severity of accidents. C. Hazards will be eliminated or controlled by correcting hazards found through safety inspections and hazard notices,providing proper personal protective equipment,supervisor enforcement of safety policies and procedures,and training programs developed to address specific safety concerns. SAFETY INSPECTIONS Safety inspections are an integral part of the overall safety program providing information of unsafe conditions and acts within the department.They furnish information which can lead to preventive correction before accidents occur. Inspectors The Safety Committee and department supervisors shall be responsible for making periodic safety inspections. Inspection Procedure The City Safety Committee shall be responsible for the determination of the location of the inspections that are to take place. Recommendations The Safety Committee shall note on the Inspection Check List, specific findings on the inspected area. • City of Oak Park Heights Safety Program Recommendations shall be made by the Safety Committee, from the information on the Inspection Check List, that will suggest action that the department should take to correct any unsafe conditions or practices in the area, if it is found that they do not exist. Everyday Inspections and Immediate Hazards The Safety Inspection Program is not designed to replace the constant everyday inspections of the supervisors, but is developed as a supplement to it. Safety hazards demanding immediate attention shall be reported by any employee to the supervisor.The supervisor,if possible,will correct the hazard or make a recommendation for its correction. • City of Oak Park Heights Safety Program SAFETY TRAINING POLICY INSTRUCTION AND TRAINING 1. Employees shall be provided initial indoctrination and such continuing instruction as will enable them to conduct their work in a proper manner. 2. Initial indoctrination shall include instruction in safety practices,reportingof all ac and individual responsibility for minimal risk operations as prescribed by the City Safety s Manual, and other applicable policies. 3. Supervisors will conduct one to five minute safety"tool box"talks on a routine basis and before special projects. Supervisors will have employees sign the meeting form and turn it in to the safety department. 4. A minimum of one 30-minute safety meetings for all workers shall be conducted each quarter by all field supervisors. 5. Persons required to use protective devices and/or equipment shall be properly instructed and trained in the use of such devices and equipment. 6. Persons required to handle flammable or other hazardous materials shall be fully instructed in the proper handling and use of such materials. 7. Persons required to work in areas where insects,rodents, snakes,poisonous plants, or other natural hazards might be encountered shall be instructed regarding potential hazards,first aid procedures,proper identification, and personal protective measures. 8. All employees will be trained in Right-to-Know, Confined Space Entry,respirators, excavation safety and all other required OSHA training before exposed to the potential hazard. • City of Oak Park Heights Safety Program CHECKLIST OF SAFETY PROGRAMS AWAIR CI Right-to-Know U Confined Space Entry CI Lock Out& Tag Out CI Forklift • Bloodborne Pathogens U Hearing Conservation CI Hoist and Hoist Monitoring CI Personal Protective Equipment U Back Injury Prevention Program O Ergonomic Program CI Respiratory Protection Program CI Fire Extinguisher Inspection Program Injury/Illness RecordOS � HA 200 Log) U Power Press Inspection U Emergency Action Plan Sling Inspections CI Electrical Safe Work Practices CI Employee Job Training U Employee Safety Committee U Violence in the Workplace • • City of Oak Park Heights Safety Program MANAGEMENT ACCIDENT REPORTING/INVESTIGATION PROCEDURES 1. Process and file all accident report forms(Supervisor's Report of Accident,First Report of Injury, property damage report,motor vehicle accident report). 2. Discuss the need for a more complete investigation with the supervisor if necessary. 3. Discuss and formulate preventive measures pertaining to work-related accidents. 4. Remain in contact with employee and employee's physician during any period which the employee misses work as a result of a work-related accident. 5. Post the accident to the OSHA 200 log within one week. 6. Post the right side of the OSHA 200 log during the month of February. ! • City of Oak Park Heights Safety Program SUPERVISOR REPORTING/INVESTIGATION PROCEDURES 1. Administer first aid and/or contact emergency personnel. 2. Notify office as soon as possible. 3. Complete appropriate accident forms and return them to the office(Supervisor's Report of Accident,First Report of Injury,property damage report,motor vehicle accident report). 4. Conduct accident investigation as instructed by management. 5. Hold safety meetings to discuss preventive measures pertaining to work related accidents. 6. If the injured employee has not returned to work,the supervisor will contact the employee at least weekly to monitor progress and determine if a modified work assignment is appropriate. O City of Oak Park Heights Safety Program ALL EMPLOYEES ACCIDENT REPORTING/INVESTIGATION PROCEDURES 1. Follow all safety rules and make an effort to prevent accidents. 2. Immediately report all accidents to the immediate supervisor. 3. Follow all medical instructions. 4. Keep the supervisor informed of changes. S City of Oak Park Heights Safety Program RETURN TO WORK POLICY The City of Oak Park Heights believes that to be successful the employees and management must work in cooperation and as a team.If you become ill or injured as a result of a job related accident, ou will missed as an active part of this team. Y be We will actively seek to return disabled employees to productive work as quickly cooperation with the employee's physician or health care provider. as possible, in If necessary,a temporary job may be provided for you that is within your physical capabilities,consistent with the city's needs.Even working at partial capacity will assist your fellow employees in com letin the work.Efforts will be made to return you to your previous job as soon as you are physical] ableg Y . • City of Oak Park Heights Safety Program DESIGNATED MEDICAL FACILITY In order to provide the best health care possible,the City has selected injuries that occur at work. has --._to treat employee experience working with work related injuries and knows how to deal with workers' compensation insurance. We feel that they can provide the best overall care. If an employee is injured,the following steps should be taken: (Supervisors will train their staff o specific details and examples relating to their department) n > Determine extent of injuries and level of treatment needed. If the injuries are life threatening, call emergency response(911)for emergencytransport. p rt. > If the injuries are not life threatening but require doctor treatment,transport the injured the(designated care provider).If necessary, person to person to an appropriate specialist for additional(designatedeatmentcare provider)will refer the injured > If the injury is minor,treat with first-aid supplies which are located If unsure about the level of action necessary,go to the next higher level. • • City of Oak Park Heights Safety Program LIGHT DUTY/TRANSITIONAL JOB PROGRAM In conjunction with the Return-to-Work Program,the City of Oak Park Heights has identif duties that an employee can perform in case of an injury. ed light Answer phones Dispatch Light filing Helper on job site We encourage injured employees to return to work as soon as possible, if not in a regular full-time capacity,then in a light duty/transitional capacity.Injured employees will be returned to their regular jobs as soon as medically feasible. The injured employee's direct supervisor,and other management,will be kept informed and progress of the Light Duty/Transitional Job Program and made aware of the injured employee'se goals restrictions. threstrictions. Injured employees performing light duty or transitional work will be evaluated dail see how they are progressing and handling the work. y to see Injured employees will sign a Return-to-Work Agreement stating that they will not do anyactivity work,home or recreation that is beyond their working restrictions. Supervisors will understand ctivity at restrictions and make sure that the injured employee follows them. (The light dutyshouave g job should have a specified time limit, such as 30 or 60 days.) • • City of Oak Park Heights Safety Program ACCIDENT REPORTING/INVESTIGATION POLICY A. The Accident Injury/Illness Investigation Report and the First Report of Injury must be completed by supervisor or department head. B. All injuries/accidents must be reported promptly(within 24 hours if possible). C. Administration or the Safety Director will review accident reports to determine if a cause has been found,corrective action suggested,and implemented. Unsafe Acts,Unsafe Conditions,and Basic or Root Causes will be identified to reveal the cause of the preventable injury or illness. See Attachment A. D. OSHA 200 Log will be maintained. ATTACHMENT A—ACCIDENT CAUSES I. IMMEDIATE CAUSES A. Unsafe Acts B. Unsafe Conditions 1.Failing to use personal protective equipment 1. Congestion of workplace 2. Failing to warn co-workers or to secure 2. Defective tools,equipment,or supplies equipment 3. Excessive noise 3. Engaging in horseplay 4. Fire and explosion hazards 4. Lifting improperly 5. Hazardous atmospheric conditions -gases, 5. Loading or placing equipment or supplies dusts,fumes,or vapors improperly 6. Inadequate supports or guards 6. Making safety devices inoperable 7. Inadequate warning systems 7. Operating equipment at improper speeds 8. Poor housekeeping 8. Operating equipment without authority 9. Poor illumination 9. Servicing equipment in motion 10. Poor ventilation 10. Taking an improper working position 11. Radiation exposure 11. Using alcoholic beverages 12. Natural cause (ex. - snow,ice) 12. Using drugs 13. Using defective equipment 14. Using equipment improperly II. BASIC ACCIDENT CAUSES A. Health and safety policy is not in writing. B. Appropriate equipment was not provided to employees. C. Training and/or supervision was not adequate. • i City of Oak Park Heights Safety Program TOP-MANAGEMENT COMMITMENT CHECKLIST Place a check mark next to each activity that top management at your city does. ❑ Issues a written injury and illness prevention policy. ❑ Wears appropriate safety gear while touring work sites. ❑ Discusses safety with employees during periodic tours. ❑ Is familiar with details of safety program and safety rules. ❑ Presents safety awards to employees. ❑ Participates,as a student, in some safety training programs(e.g. first aid,CPR,and fire extinguishers). ❑ Occasionally attends,as an observer,employee safety meetings. ❑ Keeps informed of leading causes of accidents. ❑ Receives copies of supervisors report of accident. ❑ Interviews department managers when one of their employees has a lost-time accident. ❑ Attends meetings with insurance company safety consultants. ❑ Receives copy of insurance company safety reports. ❑ Receives copy of safety committee minutes. ❑ Reviews regular reports on safety achievements. ❑ Ensures that safety is an agenda item at staff and department meetings. 0 0 0 Total Number of Check Marks • • City Of Oak Park Heights Safety Program Classification of hazard severity Prioritized correction based upon severity Employee removal from imminent danger area Documentation of all inspections and corrective actions Quality control system to ensure follow-up on corrective measures ❑ Preventative inspection and maintenance program (e.g. hoists,slings,presses,trucks,ventilation, fire protection,etc.) ❑ Personal protection equipment program,including at least following the elements: Hazard assessment • Appropriate protection equipment selected Proper fitting Proper use • Cleaning Maintenance • Replacement as required ❑ Evaluation of safety and health impact of new equipment,materials,and processes before purchase and/ or implementation SAFETY RULES& PROCEDURES ❑ General and task specific rules written ❑ Safety procedures established to comply with OSHA standards Right-to-Know Respiratory Protection • Confined Space Entry • Lock Out&Tag Out Bloodborne Pathogens • Hazardous Materials • Construction Workers Portable Fire Extinguishers • Forklifts • Hearing Conservation Fire Brigades • Servicing Rim Wheels • Personal Protective Equipment • • City Of Oak Park Heights Safety Program COMMUNICATION& TRAINING ❑ Safety and health program effectively communicated to affected employees ❑ Effective,ongoing communication (e.g. safety and health meetings,bulletin boards,signs, newsletters,booklets,accident-alert notices,safety and health committee) ❑ Effective provisions for employee input(e.g. open-door policy,suggestion program) ❑ Training program for new employees ❑ Training prior to all work assignments,including training on specific hazards (e.g. hearing conservation,respiratory protection,etc.) ❑ Training updated at least annually,or earlier if work conditions change ❑ Training records maintained (date,topic,content,attendance) ❑ Supervisors trained in applicable safety and health matters ❑ Speciali'ed training or retraining provided when needed ACCIDENT INVESTIGATION AND CORRECTIVE ACTION ❑ Supervisors trained to do investigations ❑ Accident investigation forms used ❑ All reportable accidents investigated ❑ Corrective actions identified ❑ Corrective actions implemented ❑ Written records ❑ Quality-control system to ensure proper investigation and follow-up actions ❑ Injury data maintained,summarized,and analyzed to determine specific hazards and trends (e.g. • • City Of Oak Park Heights Safety Program first reports of injury,OSHA 200 logs) U Qualified first-aid and medical services available on all shifts at all locations PROGRAM ENFORCEMENT ❑ Written enforcement statement on safe work practices,safety rules,and standard operating procedures U Records maintained on disciplinary actions and warnings U Managers and supervisors held accountable for safety and health responsibilities SAFETY PLAN ASSESSMENT U Has the plan been evaluated and modified annually • City of Oak Park Heights Safety Program ENFORCEMENT POLICY SITUATIONS AND CONSEQUENCES The following are the consequences for safety violations.Violations have been broken down by degree of seriousness: Life Threatening Consequence 1. Not following Lock Out/Tag Out procedures 2. Fall hazards 3. Noncompliance with excavation site procedures 4. Not following Confined Spaces Entry procedures 4. Not following Trenching Safety procedures 5. Not following Tower Climbing Procedures Could Turn Into Life Threatening Consequence 1. Un-Safe Vehicle Operations 2. Violation of Personal Protective Equipment Use 3. Not following established Chlorine Gas handling procedure 4. Not using proper safety equipment when using Chainsaws 5. Could Cause Serious Injury Consequence 1. Not using proper safety equipment when handling acids 2. Not using proper safety equipment when using power tools 3. Not using groundfault circuits with power tools. 4. 5. Could Cause Minor Injury Consequence 1. 2. 3. 4. • City of Oak Park Heights Safety Program EMPLOYEE WARNING NOTICE Employee Name: Date: Department: ❑ THIS IS A WARNING FOR THE REASONS LISTED BELOW: ❑ 1. Safety violations(What): ❑ 2. Absenteeism/Tardiness/Leaving work area(When): ❑ 3. Non-performance(Where/When/How): ❑ 4. Misconduct: (Where/How): ❑ 5. Other: REPEAT OF THIS VIOLATION COULD BE CAUSE FOR DISMISSAL. Employee's Signature: Your signature indicates that you have reviewed and received a copy of this warning and does not mean you agree or disagree. Department Head's Signature: City Administrator's Signature: • City of Oak Park Heights Safety Program ENFORCEMENT POLICIES The enforcement of the Safety (AWAIR)Program is critical if an effective program is to be achieved. Therefore, any safety violation will be subject to the existing progressive disciplinary procedures provided for in the City of Oak Park Height's Employee Manual. The progressive disciplinary procedure will be as follows: 1 . Employee/Supervisor Discussion Form will be completed when there is a concern over any misunderstanding of safety policies or procedures;this form is to be signed by both the supervisor and the employee. 2. First Violation--oral warning Second Violation--written warning Third Violation--suspension without pay Fourth Violation--termination 3. On the second,third and fourth offenses,the department head shall receive a copy of the violation notification to the employee. • • City Of Oak Park Heights Safety Program AWAIR CHECKLIST ELEMENTS OF AN EFFECTIVE WRITTEN AWAIR PROGRAM I• The program is in Writing. Yes Partial No II. Management Commitment and Planning Yes Partial No 1. Have policies and objectives have been established and communicated to all employees? 2. Have responsibilities been defined,authority assigned and accountability established? 3. Have adequate company resources been allocated for safety and health (staff, equipment, safety promotion, etc.)? Details: III. Hazard Assessment and Control 1. Has a comprehensive safety and health survey been done?s Partial No 2. Is there a reliable procedure for employees to use to report potentially hazardous conditions? 3. Are accidents and/or near-miss incidents that may result in an injury or illness reviewed? 4. Is there an equipment maintenance program? 5. Are engineering and personal protective equipment (PPE) controls in place as appropriate? 6. Are administrative controls,including safety and health rules, established and implemented? Details: IV. Safety Rules Yes Partial No 1. Is the effectiveness of the safety rules and procedures reviewed? 2. Are new safety rules and procedures established to adjust to accidents and new safety standards? Details: S r City Of Oak Park Heights Safety Program V. Communication Yes Parti 1. Is management involved in implementing employee safety and health?al No 2. Are there clear lines of communication for safety and health concerns? Do employees know who to notify, fear no reprisal, and receive timely and appropriate responses? Details: VI. Accident Investigation/Corrective Action 1. Are there procedures followed for investigating accidents? s Partial No 2. Are emergency plans and procedures in place? 3. Is there a follow-up procedure for corrective action? Details: VII. Enforcement ProcedureYes Partial 1. Is there an established system in place for fair and uniform enforement of company safety and health rules? 2. Is there a training procedure for employees who do not follow safety rules and procedures? Details: VIII. The Program is Annually Reviewed 1. Are results measured and analyzed? Yes Partial No 2. Are strengths and weaknesses of the safety program reviewed? 3. Are new goals and objectives established annually? Details: • • City Of Oak Park Heights Safety Program AWAIR PROGRAM EVALUATION CHECKLIST WRII-1'JN PROGRAM ❑ Written executive policy statement ❑ Written safety and health program ❑ Document showing line and staff responsibility for workplace accident and injury control ❑ Developed action plan for implementation ❑ Written program provided to employees • MANAGEMENT RESPONSIBILITY ❑ Designated a safety officer with sufficient time to do the job ❑ Assigned safety and health responsibilities ❑ Established accountability measures (e.g.lost work day incident(LWDI) rate,Workers' Compensation costs) ❑ Resources provided(e.g.money,training,materials,and personnel) ❑ Demonstrated management commitment(e.g. safety committees,incentives,management involvement in inspections,etc.) HAZARD ANALYSIS AND CONTROL ❑ Inspection program: • Departmental inspections • Critical-items inspections • Special-purpose inspections Special inspections following change in process,equipment,or employees Special inspections upon report of new hazards Specialized inspection or testing as required (e.g. noise,toxicity,etc.) ❑ Hazard control procedures: 0 0 • • off„ • i Z. r rya Wf�t ¢ ;tx i t•r' i .. � >A y' 7` d �s•..,'f, t '�` 7'� 'n`�.�" 5p,xq,�i s �z .. 1�3 p$ .,a�£"4k b f r Ng d, g•' 4 �, '�" 1s +F�l ,.! s igir`l +�.1 �^Sfih' fi '#' .Yb 7 .7 •••:4 gyp , Y ,_ o aro +t rr t , City of Oak Park Heights 14168 Oak Park Blvd. Box 2007 Oak Park Heights,MN 55082 Phone(651)439-4439 Facsimile(651)439-0574 facsimile trans • n ttai To: 3 I I b e✓-t /-t- • • • • • From: • • Date:. • , A o r'ISd Z G • 17 Q • Re: 0 r (-� %A..4� t®w 04'" Pages: 5 CC: o Urgent CI For Review Ci Please Comment 0 Reply 0 Please Recycle Notes: 1 1,1,4,r„,, raly -ov h c (it, r 7 "e--