Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2011-2752

2. Registrant Information.

Registrant Reference Number: AE2011-001.1

Registrant Name (Full Legal Name no abbreviations): Troy Chemical Corp.

Address: 1 Avenue L

City: Newark

Prov / State: N.J.

Country: USA

Postal Code: 07105

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

Human

4. Date registrant was first informed of the incident.

03-MAY-11

5. Location of incident.

Country: UNITED STATES

Prov / State: INDIANA

6. Date incident was first observed.

Unknown

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.       PMRA Submission No.       EPA Registration No. 365-7625113

Product Name: Grotan (Mergal 165)

• Active Ingredient(s)
  • HEXAHYDRO-1,3,5-TRIS(2-HYDROXYETHYL)-S-TRIAZINE
    • Guarantee/concentration 78.5 %

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7. b) Type of formulation.

Liquid

Application Information

8. Product was applied?

Yes

9. Application Rate.

.1

Units: %

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

Site: Industrial / Industriel

Préciser le type: equipment cleaning

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

0.1% Aqueous spray used by employees at Gemtron Corp. to clean 12,000 gallon open head reactor. Employees applied dilute spray then two weeks later exhibited water eyes and respiratory irritation requiring medical assistance or hospital room visit.

To be determined by Registrant

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

Yes

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

• Eye
  • Symptom - Irritated eye

• Respiratory System
  • Symptom - Burning lungs

4. How long did the symptoms last?

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

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

Contact with treated area

What was the activity? equipment cleaning

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

Long-sleeve shirt

Long pants

Goggles

Chemical resistant gloves

Respirator

10. Route(s) of exposure.

Eye

Respiratory

11. What was the length of exposure?

>2 hrs <=8 hrs / >2 h <=8 h

12. Time between exposure and onset of symptoms.

>1 wk <=1 mo / > 1 sem < = 1 mois

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.)

Hygiene Officer could not conclusively indicate symptoms were due to exposure to Grotan. Indicated they have had problems with the onsite sewer system due to excessive rain causing overflows and fumes in the plant.

To be determined by Registrant

14. Severity classification.

Moderate

15. Provide supplemental information here.

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

• Eye
  • Symptom - Irritated eye

• Respiratory System
  • Symptom - Burning lungs

4. How long did the symptoms last?

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

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

Contact with treated area

What was the activity? equipment cleaning

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

Long-sleeve shirt

Long pants

Goggles

Chemical resistant gloves

Respirator

10. Route(s) of exposure.

Eye

Respiratory

11. What was the length of exposure?

>2 hrs <=8 hrs / >2 h <=8 h

12. Time between exposure and onset of symptoms.

>1 wk <=1 mo / > 1 sem < = 1 mois

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.)

Hygiene Officer could not conclusively indicate symptoms were due to exposure to Grotan. Indicated they have had problems with the onsite sewer system due to excessive rain causing overflows and fumes in the plant.

To be determined by Registrant

14. Severity classification.

Moderate

15. Provide supplemental information here.