Print | Need Larger Text?

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2011-1486

2. Registrant Information.

Registrant Reference Number: 11691

Registrant Name (Full Legal Name no abbreviations): Troy Chemical Company Ltd., Gray Products Group

Address: 242 Applewood Crescent, Unit 14

City: Concord

Prov / State: Ontario

Country: Canada

Postal Code: L4K 4E5

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

Scientific Study

4. Date registrant was first informed of the incident.

5. Location of incident.

6. Date incident was first observed.

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.

PMRA Registration No. 11691      PMRA Submission No.       EPA Registration No. 365-76

Product Name: Grotan BK Metalworking Microbiocide

• Active Ingredient(s)
  • HEXAHYDRO-1,3,5-TRIS(2-HYDROXYETHYL)-S-TRIAZINE

7. b) Type of formulation.

Application Information

8. Product was applied?

Unknown

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 VII: Scientific Study

1. Study Reference

Title Protectol HT Acute Inhalation Toxicity Study in Wistar Rats, 4-Hour Liquid Aerosl Exposure (Head-Nose Only)

Date 19-JAN-11

2. a) Is an extension needed to translate the document?

No

3. Type of incident identified in the study

New health or environmental hazard

4. Describe the incident identified in the study (e.g. study demonstrates an increased risk to non-Hodgkin's Lymphoma after exposure to pesticide X)

New LC50 for inhalation toxicity (number) mg/L

5. a) Was the study discontinued before completion?

No

5. b) Provide the reason for discontinuation

6. If the study is ongoing, what is the expected completion date?

For Registrant use only

7. Provide supplemental information here