Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2015-7001
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.
18-MAY-13
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. 29535
PMRA Submission No.
EPA Registration No.
Product Name: Fiesta Lawn Weed Killer
- Active Ingredient(s)
- IRON (PRESENT AS FEHEDTA)
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: Res. - Out Home / Rés - à l'ext.maison
11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).
Caller reports that a tree at their property was affected by an application of pesticides product. Caller also reports that a shrub on the adjacent property was affected by an application of pesticides product. Caller indicated that it was windy when pesticides products were applied on May 17, 2013. Applicator did not turn his back to XXX XXXXX Drive when applying pesticides products on May 17, 2013.This allowed pesticides products to drift.
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
Unknown
5. Description of site where incident was observed
Fresh water
Terrestrial
Residential
Salt Water
6. Check all symptoms that apply
Visible injury ( eg. chlorosis, necrosis, bleaching)
7. Describe symptoms and outcome (died, recovered, etc.).
Caller reports that a tree at their property was affected by an application of pesticides product. Caller also reports that a shrub on the adjacent property was affected by an application of pesticides product. The damage to the plant appeared to be black leaves. Caller noted that a dandelion in the lawn turned black within hours of the application of pesticides product.
8. a) Was the incident a result of (select all that apply)
Drift
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?
No
9. b) Up to 3 days after application?
No
10. a) Was there a buffer zone?
No
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