Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2013-6719

2. Registrant Information.

Registrant Reference Number: 5149174

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.

Human

4. Date registrant was first informed of the incident.

30-SEP-13

5. Location of incident.

Country: CANADA

Prov / State: UNKNOWN

6. Date incident was first observed.

27-AUG-13

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. 18868      PMRA Submission No.       EPA Registration No.

Product Name: CIL Ambush Tree and Garden Insect Killer

• Active Ingredient(s)
  • 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: Res. - Out Home / Rés - à l'ext.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.

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

• Gastrointestinal System
  • Symptom - Dry mouth

• General
  • Symptom - Chemical taste in mouth
  • Specify - bad taste in mouth

4. How long did the symptoms last?

Unknown / Inconnu

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

Unknown

6. a) Was the person hospitalized?

Unknown

6. b) For how long?

7. Exposure scenario

Non-occupational

8. How did exposure occur? (Select all that apply)

Contact with treated area

What was the activity? ate strawberries that were covered with product

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.

Oral

11. What was the length of exposure?

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

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.)

S. FRENCH Caller states that her husband used some of CIL AMBUSH Tree and Garden Insect Killer in the garden and ate some of the strawberries from the garden. Caller states that her husband has dry mouth and a bad taste in his mouth. TOE 20 min ago O. Symptoms: Other Other A. Acute adult ingestion ASX Exposure: CIL AMBUSH Tree and Garden Insect Killer R. May cause oral and dermal irritation if residue left on mouth and skin Swish and spit Dilute w/ 4 to 6 oz of milk or water (6 8 oz if an adult) Any lip or tongue swelling, drooling or difficulty swallowing over the next 1 2 hours would indicate the need for ER eval Therapies: Dilute/irrigate/wash(Recommended), Food/snack(Recommended),

To be determined by Registrant

14. Severity classification.

Minor

15. 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.