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Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2009-5473

2. Registrant Information.

Registrant Reference Number: DASUS-252033

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

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

City: Calgary

Prov / State: Alberta

Country: Canada

Postal Code: T2P 5H1

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

Human

4. Date registrant was first informed of the incident.

5. Location of incident.

Country: UNITED STATES

Prov / State: CALIFORNIA

6. Date incident was first observed.

Unknown

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.       PMRA Submission No.       EPA Registration No.

Product Name:

• Active Ingredient(s)
  • MCPA (PRESENT AS ACID)
    • Unknown

7. b) Type of formulation.

Liquid

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 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

• General
  • Symptom - Cancer

• Nervous and Muscular Systems
  • Symptom - Anxiety
  • Specify - Emotional distress

• General
  • Symptom - Death

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?

Unknown

6. b) For how long?

7. Exposure scenario

Non-occupational

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

Other

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

Unknown

10. Route(s) of exposure.

Unknown

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.)

Plaintiffs allege that defendants used the (NAME) Center ("NAME") property to test, evaluate and apply toxic substances and in other ways caused soil to be fumigated, inundated and saturated with registered and non-registered toxic substances which migrated from the (NAME) property to plaintiffs' residencies and persons causing them loss of property value, harm and emotional distress. Dates of "application" are being in 1921 and end in 2003.

To be determined by Registrant

14. Severity classification.

Death

15. Provide supplemental information here.