Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2023-6669

2. Registrant Information.

Registrant Reference Number: 4801

Registrant Name (Full Legal Name no abbreviations): BUCKMAN LABORATORIES OF CANADA LTD.

Address: 351 Joseph-Carrier Street

City: Vaudreull-Dorion

Prov / State: Quebec

Country: Canada

Postal Code: J7V 5V5

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

Human

4. Date registrant was first informed of the incident.

21-SEP-23

5. Location of incident.

Country: CANADA

Prov / State: QUEBEC

6. Date incident was first observed.

11-SEP-23

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. 30524      PMRA Submission No.       EPA Registration No.

Product Name: BUSAN 1215 LIQUID MICROBICIDE

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

---

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

Product Name: SODIUM HYPOCHLORITE (UNSPECIFIED FORMULATION)

• Active Ingredient(s)
  • SODIUM HYPOCHLORITE

---

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 II: Human Incident Report (A separate form for each person affected)

1. Source of Report.

Other

2. Demographic information of data subject

Sex: Female

Age: Unknown / Inconnu

3. List all symptoms, using the selections below.

System

• Respiratory System
  • Symptom - Runny nose
  • Symptom - Coughing
  • Symptom - Irritated throat
  • Symptom - Sneezing

• Eye
  • Symptom - Watery eye

• Nervous and Muscular Systems
  • Symptom - Headache
  • Symptom - Dizziness

4. How long did the symptoms last?

>24 hrs <=3 days / >24 h <=3 jours

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

Occupational

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

Other

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

10. Route(s) of exposure.

Eye

Respiratory

11. What was the length of exposure?

>2 hrs <=8 hrs / >2 h <=8 h

12. Time between exposure and onset of symptoms.

>2 hrs <=8 hrs / > 2 h < = 8 h

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.)

Subject was testing and sampling solution of MCA that resulted from reaction of product with sodium hypochlorite; symptoms cleared by the next day.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.