Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2009-0024

2. Registrant Information.

Registrant Reference Number: CCW

Registrant Name (Full Legal Name no abbreviations): Clearon Corporation

Address: 95 MacCorkle Avenue SW

City: S. Charleston

Prov / State: WV

Country: USA

Postal Code: 25303

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

Human

4. Date registrant was first informed of the incident.

24-JUN-08

5. Location of incident.

Country: UNITED STATES

Prov / State: TEXAS

6. Date incident was first observed.

24-JUN-08

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.       PMRA Submission No.       EPA Registration No. 69470-20-7521712149

Product Name: Poolbrand multifunctional chlorinating granules

• Active Ingredient(s)
  • SODIUM DICHLORO-S-TRIAZINETRIONE
    • Guarantee/concentration 100 %

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

Product Name: "Super Shocker Vinyl and Plastic

• Active Ingredient(s)

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7. b) Type of formulation.

Granular

Application Information

8. Product was applied?

Yes

9. Application Rate.

5

Units: ppm

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).

Two products were mixed together, indoors, and the combination began to react and bubble. A mixture of the two products got on the skin and the exposed skin has a brown chemical burn mark. The caller and her two children were exposed for a few seconds to the gases/vapors released by the combination of materials, no respiratory symptoms were reported. Second product was "Super Shocker Vinyl and Plastic" product.

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: Female

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

3. List all symptoms, using the selections below.

System

• Skin
  • Symptom - Burns (superficial)

• Respiratory System
  • Symptom - Irritated nose

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.

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)

Application

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.

Skin

Respiratory

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.)

No details were provided and no records exist regarding medical treatment.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.

Label directions were not followed. Caller should not have mixed products together.