Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2010-5819

2. Registrant Information.

Registrant Reference Number: 680667

Registrant Name (Full Legal Name no abbreviations): McLaughlin Gormley King Company

Address: 8810 Tenth Ave North

City: Minneapolis

Prov / State: MN

Country: USA

Postal Code: 55427-4319

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

Domestic Animal

4. Date registrant was first informed of the incident.

20-AUG-10

5. Location of incident.

Country: UNITED STATES

Prov / State: ILLINOIS

6. Date incident was first observed.

15-AUG-10

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.       PMRA Submission No.       EPA Registration No. 1021-1688-8329

Product Name: Anvil 10+10 ULV

• Active Ingredient(s)
  • D-PHENOTHRIN
  • PIPERONYL BUTOXIDE
    • Guarantee/concentration 10 %

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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: Pub. Area - Outdoor/Zone publique - ext

11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).

Please refer to field 13 on Subform II or field 17 of subform III for a detailed description regarding application.

To be determined by Registrant

12. In your opinion, was the product used according to the label instructions?

Yes

Subform III: Domestic Animal Incident Report

1. Source of Report

Animal's Owner

2. Type of animal affected

Fish / Poisson

3. Breed

Freshwater Fish - Koi

4. Number of animals affected

6

5. Sex

Unknown

6. Age (provide a range if necessary )

Unknown

7. Weight (provide a range if necessary )

Unknown

8. Route(s) of exposure

Oral

Respiratory

9. What was the length of exposure?

<=15 min / <=15 min

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?

Spray drift / Dérive de pulvérisation

17. Provide any additional details about the incident

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

8/20/2010 Three days ago in the early morning, caller heard trucks spraying for mosquitoes near his yard twice around 12:30 and 1:00 in the morning. The spray equipment was calibrated at 0.52 fluid ounces per acre of undiluted product, and the in-cab data records indicate the rate in the immediate vicinity of the resident's home was 0.47 fluid ounces per acre. Later in the morning, caller found that 6 of his 8 koi fish had died. Caller had fed the fish the night before, and they all seemed asymptomatic and acting normally. Caller could not locate the other two fish. After two days, the other two fish surfaced. The two fish appear to be well, though more skittish than before. Caller also noted on the same morning increased cloudiness in his swimming pool which is about 15 feet from the koi pond. The caller's lawn was fertilized one week prior to this event, but he did not notice any changes in the koi pond or the pool afterwards.

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To be determined by Registrant

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

Death

19. Provide supplemental information here

The information contained in this report is based on self-reported statements provided to the registrant during telephone Interview(s). These self-reported descriptions of an incident have not been independently verified to be factually correct or complete descriptions of the incident. For that reason, information contained in this report does not and can not form the basis for a determination of whether the reported clinical effects are causally related to exposure to the product identified in the telephone interviews. It is unclear to what extent if at all, this pond was exposed to airborne spray of a pyrethroid-based pesticide. Pyrethroid-based pesticides are toxic to fish.