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Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2014-2245

2. Registrant Information.

Registrant Reference Number: OND

Registrant Name (Full Legal Name no abbreviations): Nalco Canada Company

Address: 1055 Truman Street PO Box 5002

City: Burlington

Prov / State: Ontario

Country: Canada

Postal Code: L7R 3Y9

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

Packaging Failure

4. Date registrant was first informed of the incident.

5. Location of incident.

Country: CANADA

Prov / State: QUEBEC

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. 31168      PMRA Submission No.       EPA Registration No.

Product Name: NALCO 60620

• Active Ingredient(s)
  • AMMONIA (PRESENT AS AMMONIUM SULFATE)

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 VI: Packaging Failure

1. What is the type of packaging that failed?

Other / Autre

specify Delivery system

2. Did packaging failure occur during?

Other

specify A pipe in the delivery system failed.

3. Did packaging failure result in?

potential exposure

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

During a restart of the delivery system there was a pipe failure. An estimated 1-2 liters of chemical product diluted with 20-30 liters of water was released to the contained area under the delivery system. The operator was near the pipe when it failed and was splashed with an unknown quantity (less than 1 liter) of the diluted chemical. He was wearing a chemical proof jacket, gloves, safety glasses, face shield and hard hat. He went directly to the nearby eyewash station and as a precaution rinsed his face and neck with water to be certain no chemical was on his skin. There was no contact with the chemical.

For Registrant use only

5. Provide supplemental information here.