Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2018-6373

2. Registrant Information.

Registrant Reference Number: 284472

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

Address: 1200 Bluegrass Lakes Parkway

City: Alpharetta

Prov / State: GA

Country: U.S.A.

Postal Code: 30004

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

Human

4. Date registrant was first informed of the incident.

18-JUN-18

5. Location of incident.

Country: CANADA

Prov / State: NEW BRUNSWICK

6. Date incident was first observed.

18-JUN-18

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. 29847      PMRA Submission No.       EPA Registration No. 1258-913

Product Name: HTH 3" Chlorinating Pucks

• Active Ingredient(s)
  • TRICHLORO-S-TRIAZINETRIONE

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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 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

• Respiratory System
  • Symptom - Respiratory irritation

4. How long did the symptoms last?

Unknown / Inconnu

5. Was medical treatment provided? Provide details in question 13.

No

6. a) Was the person hospitalized?

No

6. b) For how long?

7. Exposure scenario

Non-occupational

8. How did exposure occur? (Select all that apply)

Application

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

Unknown

10. Route(s) of exposure.

Respiratory

11. What was the length of exposure?

<=15 min / <=15 min

12. Time between exposure and onset of symptoms.

<=30 min / <=30 min

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.)

Caller states that about 5 minutes before the call he opened an 8 KG tub of the HTH 3" Chlorinating Pucks. There was a release of a chlorine odor, and moisture had built up on the inside of the container. He accidentally inhaled some of the fumes. He was having some discomfort during the call, but he said that he had read to get to fresh air and he had done that.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.