Incident Report

Subform I: General Information

1. Report Type.

Update the report

Incident Report Number: 2007-5817

2. Registrant Information.

Registrant Reference Number: PMRA-IR-0107

Registrant Name (Full Legal Name no abbreviations): Baker Petrolite Corporation

Address: 12645 West Airport Blvd.

City: Sugar Land

Prov / State: Texas

Country: USA

Postal Code: 77478

3. Select the appropriate subform(s) for the incident.

Human

4. Date registrant was first informed of the incident.

08-AUG-07

5. Location of incident.

Country: UNITED STATES

Prov / State: UTAH

6. Date incident was first observed.

07-AUG-07

Product Description

7. a) Provide the active ingredient and, if available, the registration number and product name (include all tank mixes). If the product is not registered provide a submission number.

Active(s)

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PMRA Registration No. 10948      PMRA Submission No.       EPA Registration No. 10707-9

Product Name: MAGNACIDE H Herbicide

• Active Ingredient(s)
  • ACROLEIN
    • Guarantee/concentration 95 %

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7. b) Type of formulation.

Liquid

Application Information

8. Product was applied?

Yes

9. Application Rate.

Unknown

10. Site pesticide was applied to (select all that apply).

Site: Other / Autre

Préciser le type: Water district irrigation canal

11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).

To be determined by Registrant

12. In your opinion, was the product used according to the label instructions?

Unknown

Subform II: Human Incident Report (A separate form for each person affected)

1. Source of Report.

Other

2. Demographic information of data subject

Sex: Male

Age: >19 <=64 yrs / >19 <=64 ans

3. List all symptoms, using the selections below.

System

• General
  • Symptom - Death
  • Symptom - Malaise

• Eye
  • Symptom - Decreased vision

4. How long did the symptoms last?

Persisted until death

5. Was medical treatment provided? Provide details in question 13.

Yes

6. a) Was the person hospitalized?

Yes

6. b) For how long?

6

Day(s) / Jour(s)

7. Exposure scenario

Occupational

8. How did exposure occur? (Select all that apply)

Application

9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)

Unknown

10. Route(s) of exposure.

Respiratory

11. What was the length of exposure?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

Unknown / Inconnu

13. Provide any additional details about the incident (eg. description of the frequency and severity of the symptoms, type of medical treatment, results from medical tests, outcome of the incident, amount of pesticide exposed to, etc.)

The applicator was making an application on Tuesday evening, August 7, 2007. He was alone at the location, so there were no witnesses to the events. Initial indications are that the application involved the use of more than one container. It appears that when the first container was emptied, the applicator initiated use of the second container, after which the applicator was exposed to an unknown amount of acrolein. Applicator's wife stated that he called her and said he was not feeling well and that he had difficulty seeing. The applicator was hospitalized and treated by medical professionals over the next 6 days. He passed away on (date)

To be determined by Registrant

14. Severity classification.

Death

15. Provide supplemental information here.