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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2015-2326

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.

23-AUG-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: Round up

  • Active Ingredient(s)
    • GLYPHOSATE (PRESENT AS ISOPROPYLAMINE SALT OR ETHANOLAMINE SALT)

7. b) Type of formulation.

Application Information

8. Product was applied?

Yes

9. Application Rate.

10. Site pesticide was applied to (select all that apply).

Site: Unknown / Inconnu

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

Caller says his property has been damaged by the neighbour spraying round up. He believes one of the residents along his fenceline has sprayed roundup to control thistles. Caller believes the trees along the fenceline have been sprayed and are definitely impacted. About a dozen trees about 4 feet high are dead. Everything has been killed though, not just the trees.Caller not sure believes they were sprayed in August.

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

Trees or shrubs / Arbre ou arbuste

2. Common name(s)

Unknown

3. Scientific name(s)

Unknown

4. Number of organisms affected

12

5. Description of site where incident was observed

Fresh water

Terrestrial

Other

Salt Water

6. Check all symptoms that apply

Death

Visible injury ( eg. chlorosis, necrosis, bleaching)

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

About a dozen treed are dead. Everything has been killed though, not just trees.

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

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

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

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?

No

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