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Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2022-4576

2. Registrant Information.

Registrant Reference Number: TRAP.01

Registrant Name (Full Legal Name no abbreviations): Premier Tech Limited

Address: 1, avenue Premier

City: Riviere-du-Loup

Prov / State: QC

Country: Canada

Postal Code: G5R 6C1

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

Packaging Failure

4. Date registrant was first informed of the incident.

5. Location of incident.

Country: CANADA

Prov / State: UNKNOWN

6. Date incident was first observed.

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.

PMRA Registration No. 27017      PMRA Submission No.       EPA Registration No.

Product Name: Wilson AntOut Ant Traps

• Active Ingredient(s)
  • BORAX

7. b) Type of formulation.

Application Information

8. Product was applied?

No

9. Application Rate.

10. Site pesticide was applied to (select all that apply).

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 VI: Packaging Failure

1. What is the type of packaging that failed?

Bait station / Point d'appât

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.

Oils from the peanut butter in the formulation separated and leaked through the perforated holes (ant entry points) around the ant trap. While there was potential for exposure, the risk posed by the active ingredient borax would be expected to be minimal. There is a potential for anaphylactic reaction to the peanut butter formulant. The label includes precautionary statements for the allergen.

For Registrant use only

5. Provide supplemental information here.

Amendments to the formulation will be made to accommodate the functional design of the container.