Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2010-5419

2. Registrant Information.

Registrant Reference Number: N/A

Registrant Name (Full Legal Name no abbreviations): Ashland Canada Corp.

Address: 2620 Royal Windsor Drive

City: Mississauga

Prov / State: Ontario

Country: Canada

Postal Code: L5J 4E7

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

Human

4. Date registrant was first informed of the incident.

15-OCT-10

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.

30-SEP-10

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. 19076      PMRA Submission No.       EPA Registration No.

Product Name: BIOSPERSE¿ 250 MICROBIOCIDE

• 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: Unknown / Inconnu

3. List all symptoms, using the selections below.

System

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

4. How long did the symptoms last?

Unknown / Inconnu

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

Yes

6. a) Was the person hospitalized?

No

6. b) For how long?

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)

Long-sleeve shirt

Long pants

10. Route(s) of exposure.

Skin

11. What was the length of exposure?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

>24 hrs <=3 days / >24 h <=3 jours

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.)

Employee had what appeared to be burns, blistering on his right arm. The employee went to the doctor as requested and was diagnosed with a chemical burn and given prescriptions, Bactroban Cream and Keflex. Employee was released back to work.

To be determined by Registrant

14. Severity classification.

Moderate

15. Provide supplemental information here.

Burn pattern indicated that chemical gloves for handling Biosperse 250 was not in place during the dismantling or hook up process. Chemical was allowed to make contact with employee clothing.