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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2019-4264

2. Registrant Information.

Registrant Reference Number: 315615

Registrant Name (Full Legal Name no abbreviations): Innovative Water Care, LLC

Address: 1400 Bluegrass Lakes Parkway

City: Alpharetta

Prov / State: GA

Country: U.S.A.

Postal Code: 30004

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

Domestic Animal

4. Date registrant was first informed of the incident.


5. Location of incident.


Prov / State: MARYLAND

6. Date incident was first observed.


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.


PMRA Registration No.       PMRA Submission No.       EPA Registration No. 1258-1239

Product Name: Drytec Extra Shock

  • Active Ingredient(s)
      • Guarantee/concentration 73 %

7. b) Type of formulation.


Application Information

8. Product was applied?


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?


Subform III: Domestic Animal Incident Report

1. Source of Report

Animal's Owner

2. Type of animal affected

Dog / Chien

3. Breed


4. Number of animals affected


5. Sex


6. Age (provide a range if necessary )


7. Weight (provide a range if necessary )


8. Route(s) of exposure


9. What was the length of exposure?

Unknown / Inconnu

10. Time between exposure and onset of symptoms

Unknown / Inconnu

11. List all symptoms


  • General
    • Symptom - Death

12. How long did the symptoms last?

Unknown / Inconnu

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


14. a) Was the animal hospitalized?


14. b) How long was the animal hospitalized?

15. Outcome of the incident


16. How was the animal exposed?

Other / Autre

specify Inhalation of fumes after a reaction

17. Provide any additional details about the incident

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

Caller's x year old cousin predissolved Dry Tec Extra Shock in a mop bucket in her kitchen. The caller stated that the bucket started foaming and then the product reacted. The caller described it as a "chemical bomb." The fire department was called the day of the incident. The incident occurred on memorial day. The cousin spent that night in the hospital and is seeing a specialist the day after the call (6/4/19). The caller stated that the cousin's dog passed away from the fumes.

To be determined by Registrant

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


19. Provide supplemental information here