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Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2010-2571

2. Registrant Information.

Registrant Reference Number: 06032010

Registrant Name (Full Legal Name no abbreviations): Liphatech, Inc.

Address: 3600 W. Elm Street

City: Milwaukee

Prov / State: Wisconsin

Country: USA

Postal Code: 53209

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

Human

4. Date registrant was first informed of the incident.

5. Location of incident.

Country: CANADA

Prov / State: ALBERTA

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. Unknown

Product Name: unknown

• Active Ingredient(s)
  • DIFETHIALONE

7. b) Type of formulation.

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.

Data Subject

2. Demographic information of data subject

Sex: Female

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

3. List all symptoms, using the selections below.

System

• Skin
  • Symptom - Hair loss

• Respiratory System
  • Symptom - Respiratory distress

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?

No

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)

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.)

(name)( phone # (address)

To be determined by Registrant

14. Severity classification.

Moderate

15. Provide supplemental information here.

Unknown rodenticide bait applied by "technician" hired by landlord, application made in December 2009. (name) states that bait blocks (both yellow and green in color) were crushed and scattered under heat radiator and along heat pipes. (name) states that the landlord will not disclose any further information. (name) states that she has seen a doctor concerning hair loss and respiratory problems, but has not been diagnosed or treated.