Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2012-5401

2. Registrant Information.

Registrant Reference Number: 4919225

Registrant Name (Full Legal Name no abbreviations): Sure-Gro Inc.

Address: 150 Savannah Oaks Dr.

City: Brantford

Prov / State: Ontario

Country: Canada

Postal Code: N3V 1E7

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

Domestic Animal

4. Date registrant was first informed of the incident.

08-AUG-12

5. Location of incident.

Country: CANADA

Prov / State: BRITISH COLUMBIA

6. Date incident was first observed.

09-JUL-12

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. 27587      PMRA Submission No.       EPA Registration No.

Product Name: CIL Jet Foam Wasp and Hornet Killer

• Active Ingredient(s)
  • D-TRANS ALLETHRIN
  • N-OCTYL BICYCLOHEPTENE DICARBOXIMIDE
  • PERMETHRIN

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7. b) Type of formulation.

Application Information

8. Product was applied?

Yes

9. Application Rate.

Unknown

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

Site: Unknown / Inconnu

11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).

unknown

To be determined by Registrant

12. In your opinion, was the product used according to the label instructions?

Unknown

Subform III: Domestic Animal Incident Report

1. Source of Report

Animal's Owner

2. Type of animal affected

Dog / Chien

3. Breed

Miniature Schnauzer

4. Number of animals affected

1

5. Sex

Female

6. Age (provide a range if necessary )

9

7. Weight (provide a range if necessary )

25

lbs

8. Route(s) of exposure

Oral

9. What was the length of exposure?

>15 min <=2 hrs / >15 min <=2 h

10. Time between exposure and onset of symptoms

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

11. List all symptoms

System

• Nervous and Muscular Systems
  • Symptom - Agitation
  • Symptom - Ataxia

• General
  • Symptom - Lethargy

12. How long did the symptoms last?

Unknown / Inconnu

13. Was medical treatment provided? Provide details in question 17.

Unknown

14. a) Was the animal hospitalized?

Unknown

14. b) How long was the animal hospitalized?

15. Outcome of the incident

Unknown/Inconnu

16. How was the animal exposed?

Accidental ingestion/Ingestion accident.

17. Provide any additional details about the incident

(eg. description of the frequency and severity of the symptoms

Pet owner calling because her pet ingested part of a Wasp nest approx 30 mins after being sprayed. Pet owner stated that the pet was asymptomatic until 4:00 CST yesterday when the pet became agitated, ataxic, and very lethargic. The Caller was advised that the insecticides in this product have a wide margin of safety in dogs. Significant systemic effects are not expected. Could see mild anorexia, vomiting and or diarrhea from this exposure. Pet owner should take the pet to the rDVM. Later on that day the Owner called back as her DVM who does house calls is at her home. Discussed the case with the DVM. The DVM reports the dog has a pre-exisiting fungal infection of the brain. Advised DVM that from this type of exposure we would not expect significant signs. Could see mild anorexia and or vomiting. Suspect the signs are related to the dog's pre-existing condition.

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To be determined by Registrant

18. Severity classification (if there is more than 1 possible classification

Minor

19. Provide supplemental information here

The information contained in this report is based on self-reported statements provided to the registrant during telephone Interview(s). These self-reported descriptions of an incident have not been independently verified to be factually correct or complete descriptions of the incident. For that reason, information contained in this report does not and can not form the basis for a determination of whether the reported clinical effects are causally related to exposure to the product identified.