Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2009-1365

2. Registrant Information.

Registrant Name (Full Legal Name no abbreviations): United Agri Products Canada Inc.

Address: 789 Donnybrook Drive

City: Dorchester

Prov / State: Ontario

Country: Canada

Postal Code: N0L 1G5

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

Human

4. Date registrant was first informed of the incident.

14-APR-09

5. Location of incident.

Country: CANADA

Prov / State: BRITISH COLUMBIA

6. Date incident was first observed.

14-APR-09

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. 19146      PMRA Submission No.       EPA Registration No.

Product Name: Copper Spray

• Active Ingredient(s)
  • COPPER AS ELEMENTAL (PRESENT AS COPPER OXYCHLORIDE)

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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 II: Human Incident Report (A separate form for each person affected)

1. Source of Report.

Other

2. Demographic information of data subject

Sex: Unknown

Age: Unknown / Inconnu

3. List all symptoms, using the selections below.

System

• Skin
  • Symptom - Irritated skin

4. How long did the symptoms last?

Unknown / Inconnu

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

Unknown

6. a) Was the person hospitalized?

No

6. b) For how long?

7. Exposure scenario

Occupational

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

Pesticide Spill

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

10. Route(s) of exposure.

Skin

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.)

This is a warehouse facility, the product was being loaded onto a trailer at the loading dock and a bag was punctured resulting in a very small amount spilled (25 -30 kg), one bag spilled another punctured on a truck. Affected personnel included 3 adults, age and gender unknown, human dermal and inhalation exposure. No breathing problems were reported but product was found in the nostrils so employees were sent to hospital for follow-up. No more information available at this point.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.

The incident occured at (name) Fertilizer (address) (city) (province) (postal code) (phone number) (city) (province) (country) The product involved was Copper Spray PCP#17146 (granules) ¿ not TDG regulated.