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OSHA's Form 300A (Rev. 0412004) Note: You can type Input Into this form and save it. Year ZO <br />Because the forms in this recordkeeping package are "fillablelwritable° 23 <br />PDF documents, you can type Into the Input form fields and U.S. De artment of Labor <br />Summary of Work -Related Injuries and Illnesses then save your inputs using the free Adobe PDF Reader, p <br />U.S. <br />S. D and tin Admirr/Labor <br />,•,.J. �. - - Font approved OMBno. 12180176 <br />All establishments covered by Part 1904 must complete this Summary page, even if no work -related Injuries orillnesses occurred during the year. <br />Remember to review the Log to verify that the entries are complete and accurate before completing this summary. <br />Using the Log, count the individual entries you made for each category. Then write the totals below, making sure you've added the entries from <br />every page of the Log. if you had no cases, write '0." <br />Employees, former employees, and their representatives have the right to review the OSHA Form 300 in its entirety. They also have limited access <br />to the OSHA Form 301 or Its equivalent. See 29 CFR Part 1904.35, in OSHA's mcordkesping rule, for further details on the access provisions for <br />these forms. <br />Total number of Total number of Total number of cases Total number of <br />deaths cases with days with job transferor other recordable <br />away from work restriction cases <br />0 1 0 5 <br />(a) (H) (I) (J) <br />Total number of days <br />away from work <br />5 <br />(K) <br />Total number of... <br />(M) <br />(1) Injuries <br />(2) Skin disorders <br />(3) Respiratory conditions <br />Total number of days of <br />,job transfer or restriction <br />Aa <br />0 <br />6 (4). poisonings 0 <br />0 (5) gearing loss 0 <br />0 (6) All other illnesses 0 <br />Post this Summary page from February t to April 30 of the year following the year covered by the form <br />street 13069 Orono Parkway <br />oiryElk River Stara MN Zip 55330 <br />Industry description (e.g., Mmn facrum of mafor truck frallers) <br />Municipal Utility - Electric and Water <br />North American Industrial Classification (NAICS), ifknown (e.g„ 336212) <br />1212111112121 <br />Employment information (Ifyou don't It— these figures, seethe <br />I'lorksheet on the next page to tefieude.) <br />Annual average number of employees 46 <br />Total hours worked by all employees last year 84,026.00 <br />Sign here <br />Knowingly falsifying this document may result in a fore. <br />I certify that I have examined this document and that to the /best of <br />a my�� kyo},vledge antr~ re�true, accurate, an complete <br />Company executive <br />Phnnc763-441-2020 Date February 6, 2024 <br />Reset <br />Publie repotting buicn 16r11e, collegian ofinrom u'ns unmated to avoruge 58 minutes perresponse, inoludinb nme to review doe insweuo.,—M, and gather Iht dolt needed, and <br />o,ko,vid-i—theeollectionofinfommtian. Persons are notrequired to respond to the collection orins ... roe unless it disploys o currently valid OMB conhol number. Vyoo hove ony <br />menie nbool these estimates ar ony o@a ospecta orthis data collection, conlann US Depnronent or Lobar, OSHA Off' —of St.tkticol A-1,6s, Room N-3644, No Cans aoflon Avenuq NW, <br />�tl hinglon, DC 202111. Do not send the completed forms to this office. <br />81 <br />