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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2012-0510

2. Registrant Information.

Registrant Reference Number: Ticket 2699

Registrant Name (Full Legal Name no abbreviations): Arch Chemicals, Incorporated

Address: 5660 New Northside Drive, Suite 1100

City: Atlanta

Prov / State: Georgia

Country: USA

Postal Code: 30328

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

Packaging Failure

4. Date registrant was first informed of the incident.

25-MAY-11

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.

25-MAY-11

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)

PMRA Registration No. 25839      PMRA Submission No.       EPA Registration No.

Product Name: HTH Algae Guard 10

  • Active Ingredient(s)
    • N-ALKYL (40% C12, 50% C14, 10% C16) DIMETHYL BENZYL AMMONIUM CHLORIDE

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 VI: Packaging Failure

1. What is the type of packaging that failed?

Bottle-plastic / Bouteille-plastique

2. Did packaging failure occur during?

Other

specify Caller stated the lid "popped off" when it was set down.

3. Did packaging failure result in?

potential injury

potential exposure

4. Describe how the packaging failed and the surrounding circumstances, including a description of the potential injury or exposure.

Employee was carrying bottle(s) of product. When a bottle was set down, the lid "popped off."

For Registrant use only

5. Provide supplemental information here.