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.