Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2023-2743

2. Registrant Information.

Registrant Reference Number: 2023GOWN00068328

Registrant Name (Full Legal Name no abbreviations): Gowan Company L.L.C.

Address: P.O. Box 5569

City: Yuma

Prov / State: Arizona

Country: USA

Postal Code: 85366-5569

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

Human

4. Date registrant was first informed of the incident.

23-MAY-23

5. Location of incident.

Country: CANADA

Prov / State: ALBERTA

6. Date incident was first observed.

23-MAY-23

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. 11284      PMRA Submission No.       EPA Registration No.

Product Name: EPTAM LIQUID EC HERBICIDE

• Active Ingredient(s)
  • EPTC

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7. b) Type of formulation.

Application Information

8. Product was applied?

Unknown

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

3. List all symptoms, using the selections below.

System

• Eye
  • Symptom - Burning eye

• Gastrointestinal System
  • Symptom - Nausea

• Ear
  • Symptom - Other
  • Specify - Pressure in ears

4. How long did the symptoms last?

>8 hrs <=24 hrs / > 8 h < = 24 h

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

Yes

6. a) Was the person hospitalized?

No

6. b) For how long?

7. Exposure scenario

Unknown

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.

Skin

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.)

2023GOWN00068328- The reporter indicates an exposure to a pesticide containing the active ingredient EPTC. On the day of initial contact with the registrant, the reporter indicated they were sprayed in the face and eyes with the concentrated product. They rinsed their face and eyes thoroughly and sought medical evaluation. They experienced burning eyes, nausea, and pressure in their ears. On follow-up call one day after the day of initial contact the reporter indicated their symptoms had resolved. No additional information is available.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.