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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2020-0594

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

4. Date registrant was first informed of the incident.

09-MAY-19

5. Location of incident.

Country: CANADA

Prov / State: MANITOBA

6. Date incident was first observed.

09-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. 32904      PMRA Submission No.       EPA Registration No.

Product Name: Edge MicroActiv Herbicide

  • Active Ingredient(s)
    • ETHALFLURALIN

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: Agricultural-Outdoor/Agricole-extérieur

Préciser le type: Canola

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?

No

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: Unknown / Inconnu

3. List all symptoms, using the selections below.

System

  • Eye
    • Symptom - Irritated eye

4. How long did the symptoms last?

<=30 min / <=30 min

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.

Eye

11. What was the length of exposure?

<=15 min / <=15 min

12. Time between exposure and onset of symptoms.

<=30 min / <=30 min

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.)

Caller says that he got the product in this eyes about 5 hours ago, he flushed his eyes at the time for about 10 minutes and the irritation subsided. He then went to the optometrist and had his eyes examined which came back fine. He was told to follow up with this number. He is currently asymptomatic

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.