Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2015-6446

2. Registrant Information.

Registrant Reference Number: 1-41353181

Registrant Name (Full Legal Name no abbreviations): AMVAC Chemical Corporation

Address: 4695 MacArthur Court, Suite 1200

City: Newport Beach

Prov / State: CA

Country: USA

Postal Code: 92660

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

Human

4. Date registrant was first informed of the incident.

22-JUL-15

5. Location of incident.

Country: CANADA

Prov / State: ALBERTA

6. Date incident was first observed.

22-JUL-15

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. 17110      PMRA Submission No.       EPA Registration No. 5481-446

Product Name: Woodfume

• Active Ingredient(s)
  • METAM-SODIUM

---

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: Industrial / Industriel

Préciser le type: Unknown

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

Caller stated that a patient was using the product all day for 12 hours. For the last 6 of those hours, the patient's gloves were wet from rain and soaked with the product.

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.

Other

2. Demographic information of data subject

Sex: Male

Age: Unknown / Inconnu

3. List all symptoms, using the selections below.

System

• Skin
  • Symptom - Blister

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?

No

6. b) For how long?

7. Exposure scenario

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)

Unknown

10. Route(s) of exposure.

Skin

11. What was the length of exposure?

>8 hrs <= 24 hrs / >8 h <= 24 h

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.)

Hx: Caller is a medical resident. Caller was directed to (name) from (name). Caller stated that a patient was using the product all day for 12 hours. For the last 6 of those hours, the patient's gloves were wet from rain and soaked with the product. After product use, the patient flushed his hands with water and applied baking soda which may have made symptoms worse. The patient has blisters on his hands. Concerns other that corrosive burns? A: - The product is corrosive when not diluted. Most corrosive product are no longer considered corrosive after dilution. - The main concern with dermal exoosure is corrosive burns to the skin. - Recommend 15 to 20 minutes ot rinsing it not atready pertormect. - Treat symptoms supporitively as a chemical burn. - Call back with any questions.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.

Note: After the call was completed, research indicated that the product may not have been an AMVAC product.... The US EPA registration number provided on the report is 5481-446 (Metacide 42). It is my understanding that this product has not been made by AMVAC for at least a decade, and was discontinued at the federal level in June of 2015 It is unlikely that the correct US EPA registration number was provided on the report provided to AMVAC.