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Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2015-4402

2. Registrant Information.

Registrant Reference Number: INFO183110

Registrant Name (Full Legal Name no abbreviations): Dow AgroSciences Canada Inc.

Address: Suite 2100, 450-1st Street S.W.

City: Alberta

Prov / State: Calgary

Country: Canada

Postal Code: T2P 5H1

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

Packaging Failure

4. Date registrant was first informed of the incident.

5. Location of incident.

Country: CANADA

Prov / State: SASKATCHEWAN

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.

PMRA Registration No. 14879      PMRA Submission No.       EPA Registration No.

Product Name: LORSBAN 4E INSECTICIDE

• Active Ingredient(s)
  • CHLORPYRIFOS

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 VI: Packaging Failure

1. What is the type of packaging that failed?

Jug-plastic / Cruche-plastique

2. Did packaging failure occur during?

Transportation

3. Did packaging failure result in?

potential exposure

4. Describe how the packaging failed and the surrounding circumstances, including a description of the potential injury or exposure.

Some jugs leaked due to bad seals. The total amount of spilled product was less than 1 gal. The owner was given instructions on how to clean and decontaminate the spilled area.

For Registrant use only

5. Provide supplemental information here.