Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2014-3739

2. Registrant Information.

Registrant Reference Number: PROSAR case: 1-38304103

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.

31-AUG-14

5. Location of incident.

Country: UNITED STATES

Prov / State: WASHINGTON

6. Date incident was first observed.

31-AUG-14

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. 8119-13

Product Name: Corrys Slug/Snail Pellets MP

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

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7. b) Type of formulation.

Bait

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 III: Domestic Animal Incident Report

1. Source of Report

Animal's Owner

2. Type of animal affected

Other / Autre

specify Goat

3. Breed

Unknown

4. Number of animals affected

1

5. Sex

Male

6. Age (provide a range if necessary )

Unknown

7. Weight (provide a range if necessary )

Unknown

8. Route(s) of exposure

Oral

9. What was the length of exposure?

Unknown / Inconnu

10. Time between exposure and onset of symptoms

>30 min <=2 hrs / >30 min <=2 h

11. List all symptoms

System

• Nervous and Muscular Systems
  • Symptom - Trembling

• General
  • Symptom - Abnormal behaviour
  • Specify - seems frightened

• Gastrointestinal System
  • Symptom - Other
  • Specify - borborygmi

• General
  • Symptom - Death
  • Symptom - Vocalizing

• Cardiovascular System
  • Symptom - Cardiac arrest

• Nervous and Muscular Systems
  • Symptom - Other
  • Specify - jerking
  • Symptom - Shaking

• Gastrointestinal System
  • Symptom - Other
  • Specify - stomach was rumbling

12. How long did the symptoms last?

Persisted until death

13. Was medical treatment provided? Provide details in question 17.

Yes

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?

Accidental ingestion/Ingestion accident.

17. Provide any additional details about the incident

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

1-38304103 - The reporter, a pet owner, indicated that his goat was exposed to a molluscicide containing the active ingredient metaldehyde. Two hours prior to initial contact with the registrant the reporters goat ate a couple of mouthfuls of the product and at the time of the initial call the goat was jerking, shaking, seemed frightened, was yelling and his stomach was rumbling. The reporter was advised to seek immediate medical attention. On follow-up call, two days later, the reporter indicated that the veterinarian came out about 4 hours after the exposure and gave the goat some unidentified shots (The shots may have been for sedation) but when the veterinarian tried to pump the goats stomach the goat went into cardiac arrest and died. No further information is available.

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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