Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2012-5452

2. Registrant Information.

Registrant Reference Number: x

Registrant Name (Full Legal Name no abbreviations): x

Address: x

City: x

Prov / State: x

Country: x

Postal Code: X

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

Environment

4. Date registrant was first informed of the incident.

5. Location of incident.

Country: CANADA

Prov / State: QUEBEC

6. Date incident was first observed.

20-MAY-12

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.

Product Name:

• Active Ingredient(s)
  • ATRAZINE (PLUS RELATED ACTIVE TRIAZINES)
  • AZINPHOS-METHYL
  • BROMOXYNIL
  • CLOTHIANIDIN
  • SIMAZINE PLUS RELATED ACTIVE TRIAZINES
  • THIABENDAZOLE
  • THIACLOPRID
  • THIAMETHOXAM
  • TRIFLOXYSTROBIN (CGA 279202)

---

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: Agricultural-Outdoor/Agricole-extérieur

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

A promixite du rucher majorite de culture de mais et de soya. Methodes d application principale pulverisateur pneumatique.

To be determined by Registrant

12. In your opinion, was the product used according to the label instructions?

Unknown

Subform IV: Environment (includes plants insects and wildlife)

1. Type of organism affected

Terr. Invrtbrt-Honey Bee/Inv.Ter-Abeille

2. Common name(s)

Honey bee

3. Scientific name(s)

Apis melifera

4. Number of organisms affected

Unknown

5. Description of site where incident was observed

Fresh water

Terrestrial

Agricultural

Salt Water

6. Check all symptoms that apply

Death

7. Describe symptoms and outcome (died, recovered, etc.).

Echantillon 1 200 Echantillon 2 200 Echantillon 3 200 Forte accumulation de cadavres devant l entree de la ruche. Abeilles agressives malgre une faible activite a l entree de la ruche. Tremblement chez certaines abeilles.Mort Numeros d echantillons analyses par le MAPAQ 70386901 0,015 mg g de Clothianidine, 0,003 mg g de Thiamethoxame Contenait aussi 0,001 mg g d Atrazine, 0,282 mg g d Azinphos methyl, 0,003 mg g de Bromoxynil, 0,366 mg g de Simazine, 0,002 mg g de Thiabendazole et 0,001 mg g de Trifloxystrobine. 70386902 0,013 mg g de Clothianidine, 0,005 mg g de Thiamethoxame Contenait aussi 0,287 mg g d Azinphos methyl, 0,004 mg g de Bromoxynil, 0,001 mg g de Thiabendazole, 0,002 mg g de Thiaclopride et 0,019 mg g de Trifloxystrobine. 70386903 0,015 mg g de Clothianidine, 0,002 mg g de Thiamethoxame Contenait aussi 0,001 mg g d Atrazine, 0,028 mg g d Azinphos methyl, 0,004 mg g de Thiabendazole et 0,009 mg g de Trifloxystrobine.

8. a) Was the incident a result of (select all that apply)

Unknown

8. b) i) How many times has the product been applied this year?

Unknown

8. b) ii) What was the date of the last application?

Unknown

9. Did it rain

9. a) During application?

Unknown

9. b) Up to 3 days after application?

Unknown

10. a) Was there a buffer zone?

Unknown

10. b) What type?

Terrestrial

10. c) What was the size of the buffer zone?

11. a) Were environmental samples collected and analysed?

Yes

To be determined by Registrant

12. Severity classification (if there is more than one possible classification, select the most severe)

13. Please provide supplemental information here