Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2014-2112

2. Registrant Information.

Registrant Reference Number: PROSAR case: 1-36996590

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.

04-MAY-14

5. Location of incident.

Country: UNITED STATES

Prov / State: HAWAII

6. Date incident was first observed.

04-MAY-14

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. 8119-13

Product Name: Corrys Slug/Snail Pellets MP

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

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7. b) Type of formulation.

Granular

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?

Unknown

Subform III: Domestic Animal Incident Report

1. Source of Report

Animal's Owner

2. Type of animal affected

Dog / Chien

3. Breed

Flat Coated Retriever

4. Number of animals affected

1

5. Sex

Unknown

6. Age (provide a range if necessary )

6

7. Weight (provide a range if necessary )

Unknown

8. Route(s) of exposure

Oral

9. What was the length of exposure?

Unknown / Inconnu

10. Time between exposure and onset of symptoms

Unknown / Inconnu

11. List all symptoms

System

• Nervous and Muscular Systems
  • Symptom - Other
  • Specify - Unspecified neurologic symptoms

• 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

1-36996590 - The reporter, a pet owner, indicated that her dog was exposed to a molluscicide containing the active ingredient metaldehyde. The reporter applied the product in her yard one night prior to initial contact with the registrant. The following morning the callers 6-year-old, Flat Coated Retriever (Subform III #1) and her 13-year-old, 67 pound Labrador were having neurologic symptoms. The reporter took her dogs to the veterinary clinic but on the way to the clinic the reporters Flat Coated Retriever passed away. The reporters Labrador was treated at the veterinary clinic and at the time of the initial call the dog was at home and doing fine. 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