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Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2017-2298

2. Registrant Information.

Registrant Reference Number: 170316

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

Address: 1200 Bluegrass Lakes Pkwy

City: Alpharetta

Prov / State: GA

Country: U.S.A.

Postal Code: 30004

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: UNKNOWN

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. 32187      PMRA Submission No.       EPA Registration No.

Product Name: HTH Spa Algae Kill Solution

• Active Ingredient(s)
  • POLY[OXYETHYLENE(DIMETHYLIMINIO)ETHYLENE(DIMETHYLIMINIO)ETHYLENE DICHLORIDE]

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 Product was leaking around the seal.

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.

Product was found to be leaking around the seal. All impacted product was removed from the shelf and placed in quarantine for rework. Collection and re-work is currently in-process.

For Registrant use only

5. Provide supplemental information here.