Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2022-3932

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.

01-AUG-22

5. Location of incident.

Country: UNITED STATES

Prov / State: FLORIDA

6. Date incident was first observed.

01-AUG-22

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).

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

• General
  • Symptom - Death

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

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)

Unknown

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.)

[Company] and [Company] Gainesville called concerning of a human being found inside a job they took down on August 1st. The following statement is from the Gainesville Manager [Name]...[Company] performed a tent fumigation on 7/29/2022 at [Address] Gainesville, Fl. The fumigation crew met with the sales Rep [Name] at the location at 9:04 AM and started to perform the walk-through pre-check. The interior and exterior areas were looked at, including the crawl space, which had a visual inspection performed, and the attic access ladder was pulled down for the fumigant to reach the attic space. At this time, the structure was clear of all people and animals. Later, when a set up of fans and shoot hose was performed, another inspection was performed by the team to make sure all food and medication along with no people or animals were in the structure. The house was empty from a recent move-out, and there was no furnishing or belongings. After we tented the structure, which took a couple of hours, and when it was completed around 11:45 am, [Name] and I opened all windows upstairs and downstairs. I then locked, and secondary locked all doors but the front door using split keys on all three doors. The fume crew then took lunch until around 12:30 pm and then made sure everything was set and ready to start the introduction of gas; about 5 to 10 minutes before the introduction of Vikane (sulfuryl fluoride) gas the chloropicrin was introduced to the chloropicrin pan located upstairs. I went out the front door and made sure it was locked with the split key (secondary lock), sewed up the seam and waited about 5 to 10 minutes, and introduced the sulfuryl fluoride gas at 1:28 pm.Upon arrival at the fumigation on 8/1/2022 at 1:16 pm, I walked around the fumigation, and one of the crew members, [Name], brought to my attention that a water snake that holds down the tarp to the ground was pulled off the tarp at the back of the home where the back porch is located. I put on my SCBA unit to start the 1-hour aeration. I entered the house from the front door, went to the back of the home, and opened the back doors then proceeded upstairs to remove the chloropicrin pan and shoot hose, and halfway up the stairs noticed a male lying on the floor which I proceeded back out the front door and then called my supervisor, and the supervisor then called the local police. Followup conversation on 8/8/2022: [Company] Gainesville General Manager [Name] said secondary locks were on the exterior doors, as well as signs on the exterior doors and the tarps.

To be determined by Registrant

14. Severity classification.

Death

15. Provide supplemental information here.

In the Case Review/summary statement of a report issued 8/8/2022, by [Name], Environmental Specialist II, the following conclusion was made: It appears the fumigation done at [Address] in Gainesville FL was done according to the Vikane label directions. This report was per an investigation conducted pursuant to the authority of the [Company] Law Chapter 482, F.S., and the Federal Pesticide Law, FIFRA, in response to a written directive from [State] to investigate a structural fumigation done at [Address] Gainesville FL [Postal code] where a human death occurred.