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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2012-5279

2. Registrant Information.

Registrant Reference Number: 2012-ENDCOAT-01

Registrant Name (Full Legal Name no abbreviations): TMBER SPECIALTIES CO.

Address: 35 CRAWFORD CRESCENT

City: CAMPBELLVILLE

Prov / State: ON

Country: CANADA

Postal Code: L0P 1B0

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

Human

4. Date registrant was first informed of the incident.

29-FEB-12

5. Location of incident.

Country: CANADA

Prov / State: ALBERTA

6. Date incident was first observed.

28-FEB-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)

PMRA Registration No. 19547      PMRA Submission No.       EPA Registration No. N/A

Product Name: ENDCOAT WOOD PRESERVATIVE SOFT GREEN

  • Active Ingredient(s)
    • ZINC AS ELEMENTAL (PRESENT AS ZINC NAPHTHENATE)

7. b) Type of formulation.

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).

A contractor applied the product to untreated rim joist, headers and floor joist in the crawl space of a family home on 2-28-2012 and the following day the tenant complained of nausea and vomiting from the odor of the product. Application was in violation of product label as it specifies for "exterior use only".

To be determined by Registrant

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

No

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

1. Source of Report.

Other

2. Demographic information of data subject

Sex: Unknown

Age: Unknown / Inconnu

3. List all symptoms, using the selections below.

System

  • Gastrointestinal System
    • Symptom - Nausea
    • Symptom - Vomiting

4. How long did the symptoms last?

Unknown / Inconnu

5. Was medical treatment provided? Provide details in question 13.

Unknown

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)

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.

Respiratory

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.)

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.