Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2022-6239

2. Registrant Information.

Registrant Reference Number: 255445

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

Address: 1400 Bluegrass Lakes Parkway

City: Alpharetta

Prov / State: Georgia

Country: US

Postal Code: 30004

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

Human

4. Date registrant was first informed of the incident.

04-MAY-22

5. Location of incident.

Country: CANADA

Prov / State: QUEBEC

6. Date incident was first observed.

04-MAY-22

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)

---

PMRA Registration No.       PMRA Submission No.       EPA Registration No. Unknown

Product Name: HTH Max 70

• Active Ingredient(s)
  • CALCIUM HYPOCHLORITE

---

PMRA Registration No.       PMRA Submission No.       EPA Registration No.

Product Name: Clarifier Oxidizer and Accelerator

• Active Ingredient(s)

---

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

Préciser le type: Pool

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

Caller shocked families pool with a mixure of the product listed and a second product called Clarifier Oxidizer and Accelerator by Trevi. During the treatment, the back door to the home was left open.

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: Unknown

Age: Unknown / Inconnu

3. List all symptoms, using the selections below.

System

• Respiratory System
  • Symptom - Coughing

• Eye
  • Symptom - Irritated eye
  • Symptom - Burning eye

4. How long did the symptoms last?

Unknown / Inconnu

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

No

6. a) Was the person hospitalized?

No

6. b) For how long?

7. Exposure scenario

Non-occupational

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

Application

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.

Eye

Respiratory

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.)

Caller and his family inhaled some of the chemicals of HTH Max 70 mixtured with other product, a competitor product called Clarifier Oxidizer and Accelerator, by TREVI. The back door to the home was left open, which allowed the odors from the material to waft into their home. The family experienced a slight burning or irritation to their eyes and a slight cough. They went outside for fresh air .

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.

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: Unknown / Inconnu

3. List all symptoms, using the selections below.

System

• Respiratory System
  • Symptom - Coughing

• Eye
  • Symptom - Irritated eye
  • Symptom - Burning eye

4. How long did the symptoms last?

Unknown / Inconnu

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

No

6. a) Was the person hospitalized?

No

6. b) For how long?

7. Exposure scenario

Non-occupational

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

Application

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.

Eye

Respiratory

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.)

Caller and his family (number of family members affected is unknow) inhaled some of the chemicals of HTH Max 70 mixtured with other product, a competitor product called Clarifier Oxidizer and Accelerator, by TREVI. The back door to the home was left open, which allowed the odors from the material to waft into their home. The family experienced a slight burning or irritation to their eyes and a slight cough. They went outside for fresh air .

To be determined by Registrant

14. Severity classification.

15. Provide supplemental information here.