Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2011-2089

2. Registrant Information.

Registrant Reference Number: PROSAR Case # 1-25763711

Registrant Name (Full Legal Name no abbreviations): Matson, LLC

Address: 45620 S. E. North Bend Way ¿ P.O. Box 1820

City: North Bend

Prov / State: Washington

Country: USA

Postal Code: 98045

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

Domestic Animal

4. Date registrant was first informed of the incident.

03-APR-11

5. Location of incident.

Country: UNITED STATES

Prov / State: CALIFORNIA

6. Date incident was first observed.

03-APR-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)

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PMRA Registration No.       PMRA Submission No.       EPA Registration No. 8119-11

Product Name: Corrys Slug Snail Death

• Active Ingredient(s)
  • METALDEHYDE
    • Guarantee/concentration 3.25 %

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7. b) Type of formulation.

Bait

Application Information

8. Product was applied?

Yes

9. Application Rate.

Unknown

10. Site pesticide was applied to (select all that apply).

Site: Res. - Out Home / Rés - à l'ext.maison

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?

No

Subform III: Domestic Animal Incident Report

1. Source of Report

Animal's Owner

2. Type of animal affected

Dog / Chien

3. Breed

Doberman Pinscher

4. Number of animals affected

1

5. Sex

Unknown

6. Age (provide a range if necessary )

Unknown

7. Weight (provide a range if necessary )

Unknown

8. Route(s) of exposure

Unknown

9. What was the length of exposure?

Unknown / Inconnu

10. Time between exposure and onset of symptoms

Unknown / Inconnu

11. List all symptoms

System

• General
  • Symptom - Death

12. How long did the symptoms last?

Persisted until death

13. Was medical treatment provided? Provide details in question 17.

No

14. a) Was the animal hospitalized?

No

14. b) How long was the animal hospitalized?

15. Outcome of the incident

Died

16. How was the animal exposed?

Accidental ingestion/Ingestion accident.

17. Provide any additional details about the incident

(eg. description of the frequency and severity of the symptoms

1-25763711- The reporter, a pet owner, called to indicate possible exposure of his animals to a pesticide containing the active ingredient metaldehyde. The pet owner indicated the product was applied to the back yard and his two dogs were allowed access to the application area unsupervised contrary to label recommendations. The pet owner indicated he had found his Doberman Pinscher dog in the back yard dead (Subform III, #1). The pet owner had also discovered his eighteen pound female Lhasa Apso dog (Subform III, #2) panting, rear limbs shaking salivating and in the midst of a seizure. The pet owner was advised to seek immediate veterinary care. The pet owner was advised of treatment protocols, signs seen and prognosis following ingestion of the active ingredient in domestic animals. On routine follow up the pet owner indicated the second animal was euthanized at the veterinary office due to treatment failure. No further information is available.

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To be determined by Registrant

18. Severity classification (if there is more than 1 possible classification

Death

19. Provide supplemental information here

Subform III: Domestic Animal Incident Report

1. Source of Report

Animal's Owner

2. Type of animal affected

Dog / Chien

3. Breed

Lhasa Apso

4. Number of animals affected

1

5. Sex

Female

6. Age (provide a range if necessary )

Unknown

7. Weight (provide a range if necessary )

18

lbs

8. Route(s) of exposure

Unknown

9. What was the length of exposure?

Unknown / Inconnu

10. Time between exposure and onset of symptoms

Unknown / Inconnu

11. List all symptoms

System

• Gastrointestinal System
  • Symptom - Salivating excessively

• Nervous and Muscular Systems
  • Symptom - Seizure

• Respiratory System
  • Symptom - Panting

• Nervous and Muscular Systems
  • Symptom - Muscle trembling

12. How long did the symptoms last?

Persisted until death

13. Was medical treatment provided? Provide details in question 17.

Yes

14. a) Was the animal hospitalized?

Unknown

14. b) How long was the animal hospitalized?

15. Outcome of the incident

Euthanised / Euthanasie

16. How was the animal exposed?

Accidental ingestion/Ingestion accident.

17. Provide any additional details about the incident

(eg. description of the frequency and severity of the symptoms

1-25763711- The reporter, a pet owner, called to indicate possible exposure of his animals to a pesticide containing the active ingredient metaldehyde. The pet owner indicated the product was applied to the back yard and his two dogs were allowed access to the application area unsupervised contrary to label recommendations. The pet owner indicated he had found his Doberman Pinscher dog in the back yard dead (Subform III, #1). The pet owner had also discovered his eighteen pound female Lhasa Apso dog (Subform III, #2) panting, rear limbs shaking salivating and in the midst of a seizure. The pet owner was advised to seek immediate veterinary care. The pet owner was advised of treatment protocols, signs seen and prognosis following ingestion of the active ingredient in domestic animals. On routine follow up the pet owner indicated the second animal was euthanized at the veterinary office due to treatment failure. No further information is available.

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To be determined by Registrant

18. Severity classification (if there is more than 1 possible classification

Death

19. Provide supplemental information here