Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2015-4654
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.
24-AUG-14
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: unknown
PMRA Registration No. 23005
PMRA Submission No.
EPA Registration No.
Product Name: Escort Herbicide
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: Pub. Area - Outdoor/Zone publique - ext
Préciser le type: rail line
11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).
- Spraying product was 2-4D and Escort. Rail truck sprayed at height of 2m. Application was done on August 5, 2014. Wind speed was 0-2 Kph in the morning and 2-7kph in afternoon on date of spraying. Did use an anti drift product called on target.
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
Herbaceous Plants / Plante herbacée
2. Common name(s)
Vegetables
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
Death
7. Describe symptoms and outcome (died, recovered, etc.).
reports he is concerned about spraying along the rail allowance behind his house. Caller reports a couple of days ago a very strong smell in the air and now the vegetative buffer of bushes and shrubs are all dying. Caller reports he is a cancer survivor and is very concerned about his vegetable garden and pond [ frogs have died as well]. reports he is concerned about spraying along the rail allowance behind his house. Caller reports a couple of days ago a very strong smell in the air and now the vegetative buffer of bushes and shrubs are all dying. Caller reports he is a cancer survivor and is very concerned about his vegetable garden and pond [ frogs have died as well].
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?
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