California Attorney General Xavier Becerra announced a $3,318,700 settlement with Cox Communications California, LLC (Cox) and other related entities to resolve allegations that its California facilities unlawfully disposed of hazardous waste – including hazardous batteries, electronic devices, and aerosols. These acts constitute violations of California’s Hazardous Waste Control Law, and of California’s Unfair Competition Law, as such conduct gives Cox a competitive advantage over other regulated entities that are complying with the law. Cox also is alleged to have discarded customer records without rendering personal information unreadable. This settlement was the result of a partnership between the Attorney General’s Office and the Alameda County District Attorney’s Office.
“If a company wants to do business in our state, it must abide by our laws,” said Attorney General Becerra. “Unlawfully disposing of hazardous waste can lead to serious health and environmental risks. Unlawfully disposing of personal customer information can seriously jeopardize a person’s right to privacy and open the door to identity theft. The California Department of Justice will continue working with state and local agencies to prosecute those who violate our environmental and customer record laws.”
“The Alameda County District Attorney’s Office has an environmental protection unit and a consumer protection unit dedicated to ensuring that all entities abide by state laws protecting our natural resources and consumer protection laws,” said District Attorney O’Malley. “Today’s settlement marks a victory for both the environment and for the customers of Cox Communication. The legal action also serves as a warning that companies who unlawfully dispose of hazardous waste will be brought to justice.”
As part of the settlement, Cox will:
- Pay $2,100,000 for civil penalties, $404,700 for projects furthering environmental protection, and $814,000 for reimbursement of law enforcement and investigation costs;
- Provide $450,000 in broadcast “air time” for Public Service Announcements to educate the public on how to properly dispose of and recycle consumer hazardous waste such as batteries and electronic devices;
- Spend at least $665,000 on environmental activities beyond those currently required by law in lieu of payment of $150,400 in additional civil penalties;
- Conduct three external environmental compliance audits and three internal audits to review its customer records management procedures;
- Use certified recyclers to safely recycle electronics and other recyclable materials; and
- Be bound by a permanent injunction prohibiting similar violations of law.
The settlement and final judgment follow an extensive investigation by the Attorney General’s Office and the Alameda County District Attorney’s Office. The investigation included a series of inspections of dumpsters belonging to Cox facilities. The inspections revealed that Cox was routinely and systematically sending hazardous wastes to local landfills that were not permitted to receive those wastes. Several dumpster inspections also revealed Cox disposed of customer records containing confidential personal information. During the relevant period of the investigation, Cox operated 25 facilities in California.
Register for Hazardous Waste Management and DOT Hazardous Materials Training: The Complete Course in Baton Rouge, LA on June 5-7 and save $100 or receive an Amazon Fire HD 10 tablet with electronic versions of both handbooks. To take advantage of this offer, click here or call 800-537-2372.
Chattanooga Hazardous Waste and DOT Hazardous Materials Training
Register for Hazardous Waste Management and DOT Hazardous Materials Training: The Complete Course in Chattanooga, TN on June 12-14 and save $100 or receive an Amazon Fire HD 10 tablet with electronic versions of both handbooks. To take advantage of this offer, click here or call 800-537-2372.
Dayton Hazardous Waste and DOT Hazardous Materials Training
Register for Hazardous Waste Management and DOT Hazardous Materials Training: The Complete Course in Dayton, OH on June 26-28 and save $100 or receive an Amazon Fire HD 10 tablet with electronic versions of both handbooks. To take advantage of this offer, click here or call 800-537-2372.
DOT Wants Your Input to Improve the 2020 Emergency Response Guidbbook
To assist in the gathering of information, the DOT’s Pipeline and Hazardous Materials Safety Administration (PHMSA) is soliciting input from ERG users on experiences using, and concerns with, the 2012 and 2016 editions. PHMSA is interested in any comments stakeholders and users wish to provide, but are particularly looking for answers to the following questions:
- How can PHMSA make the ERG more user-friendly for first responders during the initial response phase of a hazardous materials transportation incident? Provide examples.
- Does ERG2016 effectively emphasize the most useful information for the initial response phase?
- Have you encountered conflicting or ambiguous guidance messages when using the ERG and other sources of technical information?
- Are there ways to improve the White Pages? For example: Did you find the “How to Use this Guidebook'' flow chart on page 1 of ERG2016 useful in understanding how to use the ERG? Please explain why or why not. Do you believe PHMSA should reformat the tables, charts, and the information they provide (i.e., Table of Placards, Rail Identification Chart, and Road Trailer Identification Chart)? What changes do you think would make them more useful, clear, and easy to read and use? What other identification charts should be added, if any? What other subject(s) should be addressed? How could PHMSA improve the information the ERG provides on chemical, biological, and radiological transportation incidents? Can you suggest information to include or remove? Do you find the terms in the Glossary appropriate and current? What terms should PHMSA add? What terms should be removed or changed?
- In ERG2016's Yellow or Blue Pages, have you found any identification number and/or material name that seems to be assigned to an incorrect Guide number? If so, please note the identification number, material name, the Guide number, and suggest a new Guide number with your reasons why.
- Do the Orange Guide Pages contain recommendations and responses that are appropriate to the material they are assigned to? If not, please explain and recommend a correction.
- How could PHMSA change/improve the introduction and description of the Green Pages, or any of the following tables? Table 1--”Initial Isolation and Protective Action Distances'' Table 2--”Water Reactive Materials Which Produce Toxic Gases'' Table 3--”Initial Isolation and Protective Action Distances for Different Quantities of Six Common TIH Gases''
- When calling any of the Emergency Response Telephone Numbers listed in ERG2016, have you experienced a busy telephone line, disconnection, or no response? If so, please describe.
- What format(s) of the ERG do you use (hardcopy, electronic, online, mobile applications, etc.), and why?
- How often do you use the ERG in a dangerous goods transportation emergency? In addition to the specific questions listed in this notice, PHMSA is also interested in any supporting data and analyses that will enhance the value of the comments submitted.
Send your comments to: ERGComments@dot.gov.
Texas Revisions to the Petroleum Storage Tank Rules
May 2018 On May 9, 2018, TCEQ commissioners adopted revisions to 30 Texas Administrative Code (TAC) Chapter 334, Underground and Aboveground Storage Tanks.
The adopted rules incorporate changes from EPAs 2015 revisions to the federal underground storage tank (UST) regulations , in 40 CFR 280.
The rule revisions include:
- Periodic operation and maintenance requirements for UST systems to conduct walkthrough inspections and test UST system components,
- Requirements to ensure UST system compatibility before storing certain biofuel blends,
- New requirements to annually test specific release-detection equipment,
- Changes to comply with existing EPA release-detection requirements to monitor at least every 30 days (instead of every 35 days), and
- Minor rule revisions relating to the fee on delivery of petroleum products to reflect changes that were statutorily implemented in the Texas Water Code in 2015.
The rules were published in the Texas Register on May 25, 2018, and become effective on May 31, 2018.
Three Companies Fined for Lead Paint Exposure and Disclosure Violations
EPA announced a settlement with one Maryland company and two Virginia companies to address alleged environmental violations during renovation work at University Towers condominium development in Silver Spring, Maryland.
The three companies – HBW Properties, Inc., of Rockville, Maryland; T.S.G. Construction, LLC of Springfield, Virginia; and Hunt & Walsh, Inc. of Manassas, Virginia – will pay a total of $80,000 in penalties for violations of EPA’s Lead Renovation, Repair, and Painting Rule (RRP Rule) and TSCA.
“This settlement will safeguard communities and ensure that important lead paint rules and regulations are in place,” said EPA Regional Administrator Cosmo Servidio. “These rules ensure safe practices that protect both the public and the environment.”
Under the terms of the settlement, HBW Properties will pay $40,000; T.S.G. Construction will pay $25,000; and Hunt & Walsh will pay $15,000. The companies have also certified that they are now in compliance with all applicable RRP Rule safeguards cited by EPA.
EPA alleged that during renovation work at the University Towers condominium development, the companies failed to comply with various RRP safeguards, including:
- obtaining required EPA certification prior to initiating renovation;
- ensuring that workers performing renovation were certified or trained by a certified renovator;
- posting warning signs that clearly define work areas;
- covering the ground with protective material to collect falling paint debris;
- taking precautions to prevent the spread of dust and debris; and
- providing information pamphlets about lead to owners or tenants.
In a separate incident, EPA also announced the Metropolitan Management Group, Inc, a property management company in Wyomissing, Pennsylvania agreed to a settlement that resolves claims the company allegedly failed to provide tenants with required lead disclosure information about two rental properties.
The company was cited under the Residential Lead-Based Paint Hazard Reduction Act, which requires sellers and landlords to provide homebuyers and tenants with warning statements about lead-based paint hazards for housing built before the 1978 federal ban on lead-based paint. The law also requires home sellers and landlords to disclose known lead-based paint hazards to homebuyers and tenants (or to disclose their lack of knowledge of such hazards).
The company will pay a $20,500 penalty as part of the settlement and has certified that it is now in compliance with the requirement to provide tenants with lead-based paint hazard disclosure information.
“Lead exposure poses a significant health threat to hundreds of thousands of American children,” said EPA Mid-Atlantic Regional Administrator Cosmo Servidio. “By refocusing Agency efforts, we can work with our government partners to develop solutions that address lead exposure and improve health outcomes for children.”
EPA cited the Metropolitan Management Group for failing to provide the required warnings and disclosures about lead-based paint in leases on properties in Wyomissing and Reading, Pa. The company cooperated during the investigation and has taken corrective action to comply with the disclosure rule.
This significant settlement under the Disclosure Rule Requirements ensures that tenants learn about the risks of lead-based paint and lead-based paint hazards and how to protect themselves from such hazards. With this knowledge, tenants may make informed decisions about whether or not to rent a particular unit.
EPA is working with other federal, state, and local agencies to protect tenants and homeowners from the health risks of lead-based paint. High blood levels of lead can cause permanent damage to the nervous system and widespread health problems, such as a reduced intelligence and attention span, hearing loss, stunted growth, reading and learning problems and behavioral difficulties. Young children are most vulnerable because their nervous systems are still developing. Adults with high lead levels can suffer difficulties during pregnancy, high blood pressure, nerve disorders, memory problems and muscle and joint pain.
EPA’s RRP Rule helps protect the public from toxic lead hazards created by renovation activities involving lead-based paint. RRP safeguards are designed to ensure that “lead safe” practices are followed during the renovation and repair activities on housing built before the 1978 federal ban on lead-based paint.
According to EPA, reducing childhood lead exposure and addressing associated health impacts is a top priority.
$275,000 in Penalties for Pesticide Labeling Violations
The EPA announced a settlement with three companies involving the alleged improper labeling of pesticides manufactured at the Union Carbide Corporation pesticide production facility in Institute, West Virginia. The settling companies have agreed to ensure that pesticides are appropriately labeled.
Under separate consent agreements with EPA, Buckman Industries, Inc. of Memphis, Tennessee will pay a $160,000 penalty, Solenis, LLC of Wilmington, Delaware will pay $99,000, and Baker Petrolite of Sugarland, Texas will pay $16,000 to settle alleged violations of the Federal Insecticide, Fungicide, and Rodenticide Act (FIFRA). All the alleged violations involved the improper labeling of pesticides.
“The goal of this regulation is to promote the appropriate use of pesticides and to minimize the risks from their use to the public, pesticide applicators, and the environment,” said EPA Regional Administrator Cosmo Servidio. “This settlement will better protect public health and the environment by ensuring that products are labeled with required instructions for the safe use, disposal and recycling of pesticide containers.”
FIFRA requires the registration of pesticide products and pesticide production facilities, and the proper labeling of pesticides. This law protects public health and the environment by ensuring the safe production, handling and application of pesticides; and prevents false, misleading, or unverifiable product claims. FIFRA also prohibits the marketing of misbranded, improperly labeled, or adulterated pesticides.
EPA cited the companies following an inspection of the Union Carbide Corporation facility in Institute by officials from EPA and the West Virginia Department of Agriculture. Union Carbide, which is not a party in these enforcement actions, was contracted to manufacture pesticide products for the three companies using product labels provided by the companies.
The settling companies did not admit liability for the alleged violations, but have certified their compliance with the cited FIFRA requirements.
California Air Resources Board Inspections for Heavy-Duty Trucks Emissions Compliance
The Air Resources Board worked alongside the California Highway Patrol to conduct inspections on heavy-duty trucks traveling in the Santa Maria area. The effort was part of CARB’s enforcement campaign to ensure that clean air requirements are understood, and that big rigs are in compliance with the laws designed to improve air quality throughout California.
Measures aimed at cleaning up diesel vehicles include requirements to report fleet information to CARB, employ fuel-saving technology, install diesel soot filters and replace or upgrade aging engines and transport refrigeration units.
New Permit for Wineries Helps Protect Water Quality
Washington state wineries and the Department of Ecology have collaborated to develop the first statewide water quality permit that will help the industry prevent pollution and protect water quality.
The new Winery General Permit adopted this week establishes practices that help wineries manage their wastewater. The general permit will benefit both the state and permittees by providing broad, efficient, and consistent coverage for wineries across the state. The permit is scheduled to take effect July 1, 2019. The delayed start gives winemakers time to assess their facilities and develop a compliance strategy that best suits their business.
Ecology worked closely with local winemakers to develop a permit that provides environmental protection in way that lightens the financial and operational hardship on wineries, especially for smaller wineries, said Heather Bartlett, Ecology Water Quality Program Manager. Most of Washington’s wineries already have good practices that protect clean water. This permit will continue that standard of eco-friendly wastewater management as this industry rapidly grows.
Washington is the second largest wine-producing state in the nation. The byproduct of making wine is a corrosive wastewater that, if not properly managed, can damage soil and crops, kill aquatic life, degrade the infrastructure in wastewater treatment plants, and pull metals from the soil into groundwater that can harm people.
Ecology has worked closely with the winemaking community, stakeholders, and public since 2014 to develop this permit. The permit incorporates the best practices from wineries that already successfully manage wastewater, and time-tested practices from California’s regulations. A guiding principle was to provide flexibility for wineries covered under the permit and provide options for winemakers to comply. This will allow wineries to manage wastewater in the way that best suits their business.
Wineries may need coverage under the permit if they discharge more than 53,505 gallons of wastewater in a calendar year. Specifically, these wineries will need coverage if they discharge winery process wastewater:
- As irrigation to managed vegetation.
- To a lagoon or other liquid storage structure.
- As road dust abatement.
- To a subsurface infiltration system.
- To an infiltration basin.
- To a wastewater treatment plant.
In the coming year, Ecology will hold workshops to provide guidance to winery representatives about how to apply for coverage, inspect their facilities, document their progress, implement best management practices, and report their monitoring data to the agency.
Deadline for Commenting on EPA’s Controversial Science Data Policy Extended
On April 30, 2018, the EPA proposed a rule titled, “Strengthening Transparency in Regulatory Science.'' The Agency has extended the comment period on the proposed rule, which was scheduled to close on May 30, 2018, until August 16, 2018. The EPA also announced a public hearing to be held for the proposed rule. The hearing will be held on July 17, 2018 in Washington, DC. EPA made these changes in response to public requests for an extension of the comment period and for a public hearing.
Developer’s Bid to Overturn $595,367 San Diego Water Board Fine Denied
A San Diego County Superior Court Judge rejected housing developer, San Altos-Lemon Grove, LLC’s lawsuit to overturn a $595,367 San Diego Regional Water Quality Control Board fine for water quality violations during the construction of Valencia Hills, a 73 single family home project in the City of Lemon Grove. The Court found that the San Diego Water Board properly followed the law in adopting the penalty, and that the violations and penalty were supported by substantial evidence and a detailed enforcement order.
The violations focused on the site’s persistent lack of effective erosion and sediment controls, and subpar housekeeping practices that resulted in six sediment discharges from the Valencia Hills construction site into Encanto Channel. The Encanto Channel flows into Chollas Creek, which flows into San Diego Bay.
“This ruling demonstrates that compliance with environmental regulations is the most cost-effective
way for developers to build,” said David Gibson, executive officer for the San Diego Regional Water Board. “The San Diego Water Board appreciates the efforts made by the City of Lemon Grove to try and bring this discharger into compliance. Working together with the municipalities sends a strong message that protecting water quality should be a top priority for developers in our region.”
In August 2016, the San Diego Water Board ruled that the developer committed 81 violations of the Statewide General Construction Storm Water Permit between December 2014 and September 2015. The Court supported the Water Board’s position that violations against the developer were appropriate for days between inspections, when the inspections were only a few days apart, and agreed with the Board’s interpretation of the Permit’s requirement to cover and berm stockpiles when they are not actively being used, “consistent with the intent and the purpose of the Permit to prevent sediment from leaving the site.”
Sediment from construction activities poses a large threat to local waters because so much exposed dirt can wash off during a storm. That excess sediment can alter or obstruct flows, resulting in flooding, and it can damage local ecosystems. Abnormally high levels of sediment in the water can smother aquatic animals and habitats, and it can reduce the clarity of water, which harms the ability of organisms to breath, find food and refuge, and reproduce. Sediment can also act as a binder, carrying toxic constituents, such as metals, pesticides, and other synthetic organic chemicals with it, to our rivers, bays and ocean.
St. Joseph’s Hospital Fined $16,000 for Hazardous Waste Violations
PeaceHealth St. Joseph’s Medical Center has agreed to pay $16,000 to settle several violations of Washington’s dangerous waste laws. The violations result from inspections conducted in 2017.
The Washington Department of Ecology found that St. Joseph’s:
- Inappropriately disposed of dangerous waste by shipping it to a facility not licensed to handle that type of waste
- Had staff not properly trained to handle waste
- Failed to submit a dangerous waste report to Ecology
- Failed to conduct or document weekly inspections of waste storage areas
Hospitals deal with a variety of pharmaceuticals that can contain toxic ingredients. Even though these drugs are intended to help patients, they need to be properly handled and disposed of after use to prevent harm to the environment or threatening the health of other people.
Initially, Ecology set the fine for the violations at $24,000. However, Ecology reduced penalty based on the hospital’s past history of compliance and willingness to address the violations. Under the settlement, St. Joseph’s agrees to not appeal the fine, avoiding potentially costly litigation for both parties.
“Improperly managing hazardous waste can lead to environmental damage, and can threaten human health,” said Darin Rice, manager of Ecology’s Hazardous Waste and Toxics Reduction program. “We appreciate the hospital’s efforts to find a fast resolution to these issues and their desire to make sure violations of this nature do not happen again.”
At this time, the hospital has addressed all the issues found during the inspection.
“PeaceHealth takes its responsibility to the environment very seriously. As soon as the issues were identified we took immediate steps to ensure our processes for waste disposal are in full compliance with state law,” said St. Joseph’s Chief Operating Officer Cherie Martin.
New Research to Minimize Fire Hazards from Materials
Fire researchers will tell you that there’s a simple solution for reducing fire hazards: eliminate flammable materials. If it doesn’t burn, the experts say, then there won’t be a fire. Of course, that option isn’t very practical or realistic; after all, who wants to sit on a block of cement when you can have a cushiony recliner?
A better strategy for reducing the thousands of deaths and injuries and billions of dollars in damage resulting from the more than a million fires each year in the United States is detailed in a new research roadmap published by the National Institute of Standards and Technology (NIST). The roadmap provides guidelines for developing science-based approaches to solving numerous fire problems for multiple materials, from lightweight automobile composites to cross-laminated timbers, and prioritizes the most critical and urgent fire hazards to which they can be applied, such as upholstered furniture.
“Our hope is that this roadmap will help the global fire community develop research strategies and implementation plans for addressing fire and materials problems, now and in the future,” said NIST materials research engineer Rick Davis, one of the authors. “The roadmap identifies and describes the major challenges associated with these problems and then details potential solutions so that users such as designers and manufacturers can continue to create safer materials that still yield quality products with high consumer satisfaction and market profitability.”
The research roadmap resulted from a recent NIST-led workshop that brought together key national and international stakeholders from industry, government, academia and public laboratories.
Workshop attendees focused their discussions on four areas in which fire hazards are major concerns: innovative construction materials such as the growing use of cross-laminated wood for tall buildings; advanced polymers and composites such as polyester fabrics used in furniture and lightweight composites used in automobile bodies; next-generation fire retardants, with an emphasis on those that suppress combustion without being health hazards; and transportation and infrastructure vulnerabilities such as fire risks on trains.
For each of these areas, the experts considered the direction of current R&D and how it may impact future fire hazard reduction goals such as developing new materials, establishing product flammability standards and advancing computational tools. They also addressed emerging technologies and practices such as the increasing use of high-energy density (lithium-ion) batteries that have been in the news for flammability concerns.
The workshop participants agreed that the highest priority for future scientific studies and development projects in flammability should go to cross-cutting research approaches that can work against multiple hazards across a wide range of materials and applications. These are:
- Real fire behaviors: To understand how the actual use of a product impacts its fire service-life (the fire resistance over the life of a product) and burning behavior;
- Engineered fire-safe products: To enable the development of technologies that yield products compliant with flammability regulations for their entire lifetime; and
- Bench-scale and computational tools: To develop and use physical testing methods and computer modeling systems that accurately predict a material’s real-life fire behavior.
The new roadmap strongly recommends that these research approaches be applied to the five most critical and urgent fire hazards as defined by the experts at the recent workshop. These are: residential upholstered furniture, residential buildings in Wildland Urban Interface (WUI) communities*, timber used for multistory buildings, passenger railway cars and insulation applied to the exteriors of high-rise buildings.
“The workshop participants determined that these application areas should be prioritized for R&D because reducing flammability in all five should significantly reduce the overall losses from fires in the future,” Davis said.
The benefits from the new research roadmap, Davis said, could eventually be greater than just getting low-fire-hazard products to market. “It’s our hope that the research resulting from the roadmap will lead to science-based quality control measures, testing procedures and performance standards for materials flammability, which in turn, should reduce the costs of making products, simplify regulatory compliance for manufacturers, and provide consumers with more fire-safe product choices,” he explained.
Davis added that along with being actively engaged with its partners to promote and urge acceptance and use of the new roadmap by others, NIST has already begun putting it to work.
“Based on extensive discussions with our in-house experts after considering the roadmap’s guidelines, we are planning changes in our upcoming year’s research and modifying our long-term strategies,” he said.
More information on NIST’s efforts to reduce flammability are available online.
Sustainable Packaging Company to Divert Waste and Create Jobs with Loan from CalRecycle
The California Department of Resources Recycling and Recovery has approved a $1 million loan to expand a San Joaquin Valley company that makes bottles from recycled paper and plastic.
The Recycling Market Development Zone loan was awarded to Ecologic Brands of Manteca. It will help Ecologic utilize more California-generated cardboard, mixed paper, and plastic to make its paper bottles—diverting an estimated 488 tons of waste and creating 69 jobs in the process.
“California needs more projects like this to overcome current global market challenges—which can be greatly alleviated by building a more robust recycling infrastructure within our own state,” CalRecycle Director Scott Smithline said. “CalRecycle’s RMDZ loan program has a 25-year history of success supporting local businesses to keep valuable material out of landfills and boosting in-state markets for recyclable material.”
Ecologic will use the $1 million RMDZ loan to help fund the purchase and installation of new manufacturing equipment, which integrates paper/cardboard shells with lightweight plastic bottles to form the finished product. The equipment upgrades are projected to do three things:
- Increase diversion of recycled paper by an additional 359 tons
- Increase diversion of recycled plastic by an additional 129 tons
- Create an additional 69 jobs
Partnership Created to Restore Habitats Damaged by Oil and Hazardous Waste
NOAA and the National Fish and Wildlife Foundation have joined forces to restore habitats damaged by oil spills and hazardous waste releases in California. An initial cooperative agreement between the two organizations includes a recommendation of $1.5 million for restoration with potential for additional funding to support similar projects in other regions over the five-year time period.
The multi-year partnership will help NOAA make major progress toward restoring areas impacted from the S.S. Jacob Luckenbach and M/T Command oil spills, and the Montrose hazardous waste site. Priority activities include restoring 37 acres of kelp forest and planning for restoration of a rocky reef at the Montrose site, essential habitats supporting a diversity of fish and marine life that are important components of commercial and recreational fisheries, and other recreational industries.
The funding is part of a 2017 announcement of grants available to partners to implement projects restoring habitats and coastlines damaged by oil and chemical spills using funds recovered from those responsible for environmental harm.
NOAA’s Damage Assessment, Remediation and Restoration Program, which works across multiple offices, helps to restore natural resources after disasters like Montrose, bringing the habitat back to its condition before the incident. Since 1991, More than $10 billion has been recovered from those responsible for environmental harm to implement habitat restoration across the country.
Partnerships like this are key components of successful restoration efforts. They provide NOAA and other natural resource trustees additional options for building restoration projects to quickly address natural resource injuries. In addition, partners bring different perspectives and innovations that contribute to trustees’ restoration goals.
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Which of the following are potential side effects of lead exposure
b. Muscle weakness
c. Kidney damage
d. All of the above