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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2020-0593

2. Registrant Information.

Registrant Reference Number: 1-56513966

Registrant Name (Full Legal Name no abbreviations): Gowan Company LLC

Address: P.O. Box 5569

City: Yuma

Prov / State: Arizona

Country: USA

Postal Code: 58366

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

Human

Packaging Failure

4. Date registrant was first informed of the incident.

08-MAY-19

5. Location of incident.

Country: CANADA

Prov / State: SASKATCHEWAN

6. Date incident was first observed.

08-MAY-19

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. 25112      PMRA Submission No.       EPA Registration No.

Product Name: Avadex MicroActiv Herbicide

  • Active Ingredient(s)
    • TRIALLATE

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: Other / Autre

Préciser le type: Not Specified

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?

Yes

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: Female

Age: Unknown / Inconnu

3. List all symptoms, using the selections below.

4. How long did the symptoms last?

Unknown / Inconnu

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

No

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)

Other

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.

Respiratory

11. What was the length of exposure?

<=15 min / <=15 min

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.)

We have some of the bags in a shed and the bags have disintegrated a little bit. While cleaning them up, I inhaled a little bit of the dust and am worried because I am pregnant, but I am currently asymptomatic. All the the bags have been contained and are ready for pick-up.**Caller said she did not need clean-up assistance.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.

Subform VI: Packaging Failure

1. What is the type of packaging that failed?

Bag-paper / Sac-papier

2. Did packaging failure occur during?

Storage

3. Did packaging failure result in?

potential exposure

4. Describe how the packaging failed and the surrounding circumstances, including a description of the potential injury or exposure.

We have some of the bags in a shed and the bags have disintegrated a little bit. While cleaning them up, I inhaled a little bitof the dust and am worried because I am pregnant, but I am currently asymptomatic. All the the bags have been contained andare ready for pick-up.

For Registrant use only

5. Provide supplemental information here.