Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2021-1672

2. Registrant Information.

Registrant Reference Number: 28240

Registrant Name (Full Legal Name no abbreviations): Douglas Products and Packaging Company, LLC

Address: 1550 East Old 210 Hwy

City: Liberty

Prov / State: MO

Country: The United States of America

Postal Code: 64068

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

Human

4. Date registrant was first informed of the incident.

16-APR-21

5. Location of incident.

Country: UNITED STATES

Prov / State: CALIFORNIA

6. Date incident was first observed.

16-APR-21

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. 28240      PMRA Submission No.       EPA Registration No. 1015-78

Product Name: VIKANE

• Active Ingredient(s)
  • SULFURYL FLUORIDE
    • Guarantee/concentration 99.8 %

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PMRA Registration No.       PMRA Submission No.       EPA Registration No.

Product Name: chloropicrin

• Active Ingredient(s)
  • CHLOROPICRIN

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7. b) Type of formulation.

Other (specify)

Fumigant

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).

Application was to single family home and two other detached structures all under the same tarp system.

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.

Other

2. Demographic information of data subject

Sex: Male

Age: >19 <=64 yrs / >19 <=64 ans

3. List all symptoms, using the selections below.

System

• General
  • Symptom - Death

4. How long did the symptoms last?

Persisted until death

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

Non-occupational

8. How did exposure occur? (Select all that apply)

9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)

None

10. Route(s) of exposure.

Unknown

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.)

Brief Incident Description Notes. On 4/14/21 at around 2:50 pm X shot Vikane in a single family home and two other detached structures. 5 to 10 minutes prior to the introduction of Vikane a total of 1.5 oz of chloropicrin was introduced in a single family home and a detached garage. On 4/15/21 at round 11:45 am X began the aeration process for the home. He saw that a water snake was out of place, and upon direction of his manager X he adjusted the water snake and continued the aeration as normal. On 4/16/21 at around 10:00 am X noticed a body on the ground next to the house under the tarps. The property consisted of a main house and detached structures which were enveloped in the same tarps. The body was found under the tarps between the main home and detached structure. He stopped the job and called the police and his management team. X responded and went to the job site, and he informed the local AG department and the structural pest control board. I arrived at the scene at 11:45 am and by that time law enforcement was at the scene and had pronounced the person as deceased. X was instructed to finish the clearing/certification of the home so they could investigate inside. Upon investigation they found a broken window and a bucket near the broken window. Law enforcement inform me that the deceased entered the home through the broken window, and cut himself upon entry of the home. During their investigation they found a blood trail throughout the home from the deceased and drug paraphernalia in the home that the home owners said didn't belong to them. By the time I had arrived at the scene the house was cleared for certification and upon review of the fume log and interviewing those involved with the fumigation process, I could find no signs of anything done improperly by the fumigation company.

To be determined by Registrant

14. Severity classification.

Death

15. Provide supplemental information here.