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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2015-2304

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: ONTARIO

6. Date incident was first observed.

21-APR-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: Polydex (non-specific)

  • Active Ingredient(s)
    • Copper (present as copper sulfate pentahydrate)

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: Other / Autre

Préciser le type: pond

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

The pond was formed from an old gravel pit. Caller says Polydex was applied to the pond on Monday the 16th. Polydex reported to contain copper sulphate. Dead fish were found in front of Lot 1 and 2, the north west corner of the pond and the western side common area and common beach.

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

Fish - Schooling/Poisson-Vivant en banc

2. Common name(s)

Crappie

3. Scientific name(s)

Pomoxis (genus)

4. Number of organisms affected

35

5. Description of site where incident was observed

Fresh water

Pond

Terrestrial

Salt Water

6. Check all symptoms that apply

Death

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

Caller reports 30 to 40 small, 1 to 2 inches, dead fish in self-enclosed shallow water pond on the estates where she resides. Caller cannot tell if more than one species involved.

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

Application

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

1

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

16-APR-12

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?

Aquatic

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