Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2007-5204

2. Registrant Information.

Registrant Reference Number: 196139

Registrant Name (Full Legal Name no abbreviations): Dow AgroSciences, LLC

Address: 9330 Zionsville Road

City: Indianapolis

Prov / State: IN

Country: United States

Postal Code: 46268

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

Human

4. Date registrant was first informed of the incident.

13-JUN-07

5. Location of incident.

Country: UNITED STATES

Prov / State: CALIFORNIA

6. Date incident was first observed.

02-JUN-07

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.

Product Name: Vikane Gas Fumigant

• Active Ingredient(s)
  • SULFURYL FLUORIDE
    • Unknown

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7. b) Type of formulation.

Other (specify)

Gas Fumigant

Application Information

8. Product was applied?

Yes

9. Application Rate.

Unknown

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

Site: Res. - In Home / Rés. - à l'int. 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 II: Human Incident Report (A separate form for each person affected)

1. Source of Report.

Other

2. Demographic information of data subject

Sex: Male

Age: >19 <=64 yrs / >19 <=64 ans

3. List all symptoms, using the selections below.

System

• Cardiovascular System
  • Symptom - Cardiac arrest

4. How long did the symptoms last?

Unknown / Inconnu

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

Yes

6. a) Was the person hospitalized?

Yes

6. b) For how long?

Unknown

7. Exposure scenario

Non-occupational

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

Contact with treated area

What was the activity? Breaking and entering

Other

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

None

10. Route(s) of exposure.

Eye

Respiratory

11. What was the length of exposure?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

Unknown / Inconnu

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.)

Escaped parolee broke into tarped home where product had been applied 3 days earlier. When discovered on sofa with syringe, shotgun and handcuff on one wrist, man walked out of home at own will under medical escort. Went into cardiac arrest in ambulance in route to hospital. Patient released after recovery from cardiac arrest.

To be determined by Registrant

14. Severity classification.

Major

15. Provide supplemental information here.