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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2010-4510

2. Registrant Information.

Registrant Reference Number: PROSAR Case # 1-23926701

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: Washington

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.

26-AUG-10

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.

Active(s)

PMRA Registration No.       PMRA Submission No.       EPA Registration No. 8119-13

Product Name: Corrys Slug Snail Pellets

  • Active Ingredient(s)
    • METALDEHYDE
      • Guarantee/concentration 3.25 %

7. b) Type of formulation.

Other (specify)

pellets

Application Information

8. Product was applied?

Yes

9. Application Rate.

Unknown

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

Site: Res. - Out Home / Rés - à l'ext.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 III: Domestic Animal Incident Report

1. Source of Report

Animal's Owner

2. Type of animal affected

Fish / Poisson

3. Breed

fancy goldfish

4. Number of animals affected

11

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?

Unknown / Inconnu

10. Time between exposure and onset of symptoms

Unknown / Inconnu

11. List all symptoms

System

  • General
    • Symptom - Other
    • Specify - not swimming well
    • 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 potential run off from adjacent treated area (backyard pond)

17. Provide any additional details about the incident

(eg. description of the frequency and severity of the symptoms

1-23926701- The reporter, a pet owner, calls to indicate possible exposure of his animals to a pesticide containing the active ingredient metaldehyde. The caller indicates he has a backyard fish pond containing fancy gold fish and Koy. He indicates at some indeterminate time prior to the initial call with the registrant he had applied the product around the pond. He reports of the twelve fancy goldfish eleven (Sub-form III#1) are swimming poorly at the bottom of the pond but still alive. His one Koy fish in the pond is well. The caller states he sees several dead snails around the pond and wonders if run off of the product may affect his fish. Metaldehyde toxicity in fish species available discussed with caller. Charcoal filtration and water exchange was recommended with caution not to further shock the animals. On routine follow-up the caller revealed his fish were eaten by a wild animal, he believed a raccoon. He was unsure if they were alive or dead when they were taken. No further information is available.


To be determined by Registrant

18. Severity classification (if there is more than 1 possible classification

Death

19. Provide supplemental information here