Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2019-2986

2. Registrant Information.

Registrant Reference Number: 2019-06-14SR

Registrant Name (Full Legal Name no abbreviations): Solesco Inc.

Address: 2405 rue de Celles, unite 5

City: Quebec

Prov / State: Quebec

Country: Canada

Postal Code: G2C 1K7

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

Human

Packaging Failure

4. Date registrant was first informed of the incident.

14-JUN-19

5. Location of incident.

Country: CANADA

Prov / State: QUEBEC

6. Date incident was first observed.

12-JUN-19

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. 32790      PMRA Submission No.       EPA Registration No.

Product Name: Solubact-IZ 15

• Active Ingredient(s)
  • CHLORO-5 METHYL-2 ISOTHIAZOLINE-4 ONE-3
  • METHYL-2 ISOTHIAZOLINE-4 ONE-3

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7. b) Type of formulation.

Application Information

8. Product was applied?

No

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

• Skin
  • Symptom - Burns (2nd or 3rd degree)
  • Symptom - Blister
  • Symptom - Pain
  • Symptom - Itchy skin
  • Symptom - Cracked skin
  • Symptom - Inflammation of the skin
  • Symptom - Irritated skin
  • Symptom - Lesion
  • Symptom - Red skin
  • Symptom - Skin sensitivity

4. How long did the symptoms last?

>1 wk <=1 mo / > 1 sem < = 1 mois

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

Occupational

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)

10. Route(s) of exposure.

Skin

11. What was the length of exposure?

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

12. Time between exposure and onset of symptoms.

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

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.)

Lors de la livraison du produit au client, le livreur (personne affectee) a verifie que le contenant etait bien ferme. Il semble qu'il y avait presence du liquide sur la surface du contenant lors de cette verification. Le livreur portait alors des gants de travail non-impermeables, et le produit a pu penetrer les gants. Le livreur ne s'en est pas rendu compte, et a continue a porter ses gants, prolongeant ainsi l'exposition pour une duree exacte inconnue. Cette exposition s'est produite aux environs de midi. Arrive a la maison le soir, le livreur s'est appercu que ses doigts etaient enfles et brules. Il s'est dirige a la pharmacie pour demander conseil. Le pharmacien de service lui a indique qu'il n'etait pas necessaire d'aller a l'urgence et lui a suggere un traitement pour les brulures. Les doigts exposes ont forme des cloques apres quelques temps, et moins d'une semaine apres l'exposition la peau etait sur le vif. Lorsque le livreur pliait ses doigts, la peau se fissurait et saignait.

To be determined by Registrant

14. Severity classification.

Moderate

15. Provide supplemental information here.

La personne affectee n'a pas due ere placee en arret de travail et ne subira vraisemblablement aucune consequence a long terme de son exposition. Cependant, l'exposition non-traitee presente des risques d'infection. Le pharmacien a conseille un onguent antiseptique pour cette raison.

Subform VI: Packaging Failure

1. What is the type of packaging that failed?

Jug-plastic / Cruche-plastique

2. Did packaging failure occur during?

Transportation

3. Did packaging failure result in?

potential injury

potential exposure

4. Describe how the packaging failed and the surrounding circumstances, including a description of the potential injury or exposure.

Le contenant a vraisemblablement fuit durant le transport, expliquant le contact du livreur avec le produit et la brulure rapportee. Il est probable que le bouchon du contenant n'ait pas ete suffisamment serre. Suivant cet indident, les bidons ne seront plus utilises pour transporter les pesticides.

For Registrant use only

5. Provide supplemental information here.