Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2014-2396

2. Registrant Information.

Registrant Reference Number: Shikoku1

Registrant Name (Full Legal Name no abbreviations): SHIKOKU CHEMICALS CORPORATION

Address: B16, 1-3 NAKASE

City: MIHAMA-KU

Prov / State: CHIBA

Country: JAPAN

Postal Code: 261 8501

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

Human

4. Date registrant was first informed of the incident.

10-MAR-14

5. Location of incident.

Country: CANADA

Prov / State: BRITISH COLUMBIA

6. Date incident was first observed.

01-DEC-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. 19503      PMRA Submission No.       EPA Registration No. 33980 3

Product Name: NEO CHLOR 55 STABILIZED CHLORINATING GRANULES

• Active Ingredient(s)
  • AVAILABLE CHLORINE, PRESENT AS SODIUM DICHLORO-S-TRIAZINETRIONE

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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.

Other

2. Demographic information of data subject

Sex: Female

Age: Unknown / Inconnu

3. List all symptoms, using the selections below.

System

• Skin
  • Symptom - Rash

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

Unknown

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

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

11. What was the length of exposure?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

Unknown / Inconnu

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.)

Incident occurred using the scheduled swimming pool product OMNI STABILIZED GRANULAR CHLORINE. NEO CHLOR 55 STABILIZED CHLORINATING GRANULES is the technical active ingredient product used in OMNI STABILIZED GRANULAR CHLORINE.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.