Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2012-2164

2. Registrant Information.

Registrant Reference Number: PROSAR Case #: 1-30089299

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.

Human

4. Date registrant was first informed of the incident.

12-MAY-12

5. Location of incident.

Country: UNITED STATES

Prov / State: UTAH

6. Date incident was first observed.

11-MAY-12

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. 8119-11

Product Name: Corrys Slug and Snail Death (non-specific)

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

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7. b) Type of formulation.

Bait

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 II: Human Incident Report (A separate form for each person affected)

1. Source of Report.

Data Subject

2. Demographic information of data subject

Sex: Male

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

3. List all symptoms, using the selections below.

System

• Gastrointestinal System
  • Symptom - Nausea

• Cardiovascular System
  • Symptom - Tachycardia

• General
  • Symptom - Sweating

• Cardiovascular System
  • Symptom - Arrhythmia
  • Specify - Atrial Fibrillation

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?

Unknown

6. b) For how long?

7. Exposure scenario

Non-occupational

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

Application

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

None

10. Route(s) of exposure.

Skin

11. What was the length of exposure?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

>2 hrs <=8 hrs / > 2 h < = 8 h

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.)

1-30089299- The reporter indicted her spouse was exposed to a pesticide containing the active ingredient metaldehyde. The caller reported her husband was applying the product by hand earlier the same day of her initial contact. He was at the time of the call experiencing symptoms of nausea, rapid heart rate, and perspiration. The caller was advised dermal contact with the product would not be expected to elicit the symptoms described; he should seek immediate medical assistance. Three days later follow up was obtained. The caller reported her husband was seen at the emergency room where he was found to have an irregular heart rhythm. Medication was administered and he had follow up planned with a cardiologist to address the finding. The symptoms seen are inconsistent with the expectations of the active ingredient. No further information is available.

To be determined by Registrant

14. Severity classification.

Major

15. Provide supplemental information here.