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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2012-3258

2. Registrant Information.

Registrant Reference Number: 246A-102

Registrant Name (Full Legal Name no abbreviations): Amvac Chemical Corporation

Address: 4695 MacArthur Court, Suite 1200

City: Newport Beach

Prov / State: California

Country: U.S.A.

Postal Code: 92660

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

Scientific Study

4. Date registrant was first informed of the incident.

5. Location of incident.

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.

Active(s)

PMRA Registration No. 19723      PMRA Submission No.       EPA Registration No. 5481-96

Product Name: Technical DDVP

  • Active Ingredient(s)
    • DICHLORVOS PLUS RELATED ACTIVE COMPOUNDS

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 VII: Scientific Study

1. Study Reference

Title Dichloroacetic Acid: Acute Toxicity to Daphnia Magna

Date 17-AUG-12

2. a) Is an extension needed to translate the document?

No

3. Type of incident identified in the study

New health or environmental hazard

4. Describe the incident identified in the study (e.g. study demonstrates an increased risk to non-Hodgkin's Lymphoma after exposure to pesticide X)

Results provided could possible suggest an adverse finding

5. a) Was the study discontinued before completion?

No

5. b) Provide the reason for discontinuation

6. If the study is ongoing, what is the expected completion date?

For Registrant use only

7. Provide supplemental information here