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Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2010-2137
2. Registrant Information.
Registrant Reference Number: PROSAR Case # 1-22372581
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: WA
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.
23-APR-105. Location of incident.
Country: UNITED STATES
Prov / State: WASHINGTON
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.
Active(s)PMRA Registration No. PMRA Submission No. EPA Registration No. 8119-6
Product Name: Deadline Force II Slug Snail Killer
- Active Ingredient(s)
- METALDEHYDE
- Guarantee/concentration 4 %
- METALDEHYDE
7. b) Type of formulation.
Liquid
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).
The product was applied to plants that were one month later transferred to floating planting beds that were floated on ponds in a greenhouseTo 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
Fish / Poisson
3. Breed
Koi
4. Number of animals affected
20
5. Sex
Unknown
6. Age (provide a range if necessary )
Unknown
7. Weight (provide a range if necessary )
Unknown
8. Route(s) of exposure
Unknown
9. What was the length of exposure?
>1 wk <=1 mo / > 1 sem < = 1 mois
10. Time between exposure and onset of symptoms
Unknown / Inconnu
11. List all symptoms
System
- 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?
Other / Autre
specify The product was applied to plants that were one month later transferred to floating planting beds that were placed on the fish pond
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
1-22372581: The reporter (fish owner) called on 04/23/2010 to report exposure of his fish to a pesticide containing the active ingredient Metaldehyde. The reporter indicates he applied the product to plants one month ago that were placed in floating planting beds that were floated over fish a fish pond in his green house. Application technique was not provided. One month later he has noted spontaneous death of 20 Koi fish (animal 1 Sub form III), 100 Mosquito fish (animal 2 sub form III), and 30 Catfish (animal 3 sub form III). The caller had not submitted any animals for necropsy or reported any water analysis. The reporter was advised the deaths would be unexpected to be associated with the description of the exposure based on data available for other species of fish.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Death
19. Provide supplemental information here
Subform III: Domestic Animal Incident Report
1. Source of Report
Animal's Owner
2. Type of animal affected
Fish / Poisson
3. Breed
Mosquito fish
4. Number of animals affected
100
5. Sex
Unknown
6. Age (provide a range if necessary )
Unknown
7. Weight (provide a range if necessary )
Unknown
8. Route(s) of exposure
Unknown
9. What was the length of exposure?
>1 wk <=1 mo / > 1 sem < = 1 mois
10. Time between exposure and onset of symptoms
Unknown / Inconnu
11. List all symptoms
System
- 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?
Other / Autre
specify The product was applied to plants that were one month later transferred to floating planting beds that were placed on the fish pond
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
1-22372581: The reporter (fish owner) called on 04/23/2010 to report exposure of his fish to a pesticide containing the active ingredient Metaldehyde. The reporter indicates he applied the product to plants one month ago that were placed in floating planting beds that were floated over fish a fish pond in his green house. Application technique was not provided. One month later he has noted spontaneous death of 20 Koi fish (animal 1 Sub form III), 100 Mosquito fish (animal 2 sub form III), and 30 Catfish (animal 3 sub form III). The caller had not submitted any animals for necropsy or reported any water analysis. The reporter was advised the deaths would be unexpected to be associated with the description of the exposure based on data available for other species of fish.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Death
19. Provide supplemental information here
Subform III: Domestic Animal Incident Report
1. Source of Report
Animal's Owner
2. Type of animal affected
Fish / Poisson
3. Breed
Catfish
4. Number of animals affected
30
5. Sex
Unknown
6. Age (provide a range if necessary )
Unknown
7. Weight (provide a range if necessary )
Unknown
8. Route(s) of exposure
Unknown
9. What was the length of exposure?
>1 wk <=1 mo / > 1 sem < = 1 mois
10. Time between exposure and onset of symptoms
Unknown / Inconnu
11. List all symptoms
System
- 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?
Other / Autre
specify The product was applied to plants that were one month later transferred to floating planting beds that were placed on the fish pond
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
1-22372581: The reporter (fish owner) called on 04/23/2010 to report exposure of his fish to a pesticide containing the active ingredient Metaldehyde. The reporter indicates he applied the product to plants one month ago that were placed in floating planting beds that were floated over fish a fish pond in his green house. Application technique was not provided. One month later he has noted spontaneous death of 20 Koi fish (animal 1 Sub form III), 100 Mosquito fish (animal 2 sub form III), and 30 Catfish (animal 3 sub form III). The caller had not submitted any animals for necropsy or reported any water analysis. The reporter was advised the deaths would be unexpected to be associated with the description of the exposure based on data available for other species of fish.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Death
