Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2007-8067

2. Registrant Information.

Registrant Reference Number: 2007-IR-02 05Nov07

Registrant Name (Full Legal Name no abbreviations): Nalco Canada Company

Address: 1055 Truman Street

City: Burlington

Prov / State: Ontario

Country: Canada

Postal Code: L7R 3V9

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

Human

4. Date registrant was first informed of the incident.

02-NOV-07

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.

02-NOV-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. 17338      PMRA Submission No.       EPA Registration No.

Product Name: Nalco 7330 Cooling Water and Industrial Process Water Slimicide

• Active Ingredient(s)
  • 2-METHYL-4-ISOTHIAZOLIN-3-ONE
  • 5-CHLORO-2-METHYL-4-ISOTHIAZOLIN-3-ONE

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7. b) Type of formulation.

Application Information

8. Product was applied?

No

9. Application Rate.

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

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

• Skin
  • Symptom - Burns (2nd or 3rd degree)

4. How long did the symptoms last?

>3 days <=1 wk / >3 jours <=1 sem

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

Yes

6. a) Was the person hospitalized?

Yes

6. b) For how long?

2

Day(s) / Jour(s)

7. Exposure scenario

Occupational

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

Pesticide Spill

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

Goggles

Chemical resistant gloves

10. Route(s) of exposure.

Skin

11. What was the length of exposure?

<=15 min / <=15 min

12. Time between exposure and onset of symptoms.

>8 hrs <=24 hrs / > 8 h < = 24 h

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.)

Approximately 250 mL of product was sitting on top of the 116 kg plastic drum. The worker was wearing PVC jacket, face shield with safety glasses and nitrile gloves. The product splashed onto his legs when the drum was tipped. This happened Sat. Oct. 27/07 at 7:00 pm. Approximately 10 minutes later he washed up. Later that evening he noticed red skin on his leg. Sunday morning bubbles appeared. Monday morning he went to his Doctor and was sent home. Monday night the bubbles were breaking and he went to the hospital. He was admitted to the hospital 10 pm Monday evening and was treated for 3rd degree burn between the knee and the ankle, and treated with IV strong antibiotics. He was released from hospital Wednesday morning (Oct 31/07).

To be determined by Registrant

14. Severity classification.

Moderate

15. Provide supplemental information here.