Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2017-3741
2. Registrant Information.
Registrant Reference Number: 18355
Registrant Name (Full Legal Name no abbreviations): Woodstream Canada Corporation
Address: 25 Bramtree Court, Unit 1
City: Brampton
Prov / State: Ontario
Country: Canada
Postal Code: L6S 6G2
3. Select the appropriate subform(s) for the incident.
Environment
4. Date registrant was first informed of the incident.
17-JUL-17
5. Location of incident.
Country: CANADA
Prov / State: ONTARIO
6. Date incident was first observed.
17-JUL-17
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. 18355
PMRA Submission No.
EPA Registration No.
Product Name: Safer's Rose & Flower Insecticide R.T.U
- Active Ingredient(s)
- POTASSIUM SALTS OF FATTY ACIDS
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: 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).
Product was applied 2x over the course of 7 days. Consumer shook the bottle well prior to applying the product onto the top and bottom of leaves/flowers in hanging basket. Several of the hanging flowers died, and several others were dying when the report was made.
To be determined by Registrant
12. In your opinion, was the product used according to the label instructions?
Yes
Subform IV: Environment (includes plants insects and wildlife)
1. Type of organism affected
Herbaceous Plants / Plante herbacée
2. Common name(s)
Flowers
3. Scientific name(s)
Unknown
4. Number of organisms affected
5
5. Description of site where incident was observed
Fresh water
Terrestrial
Residential
Salt Water
6. Check all symptoms that apply
Death
Epinasty (leaf wilt)
7. Describe symptoms and outcome (died, recovered, etc.).
Flowers 2 of the plants in hanging baskets died, while the other 3 were dying as of the phone call.
8. a) Was the incident a result of (select all that apply)
Application
N/A
8. b) i) How many times has the product been applied this year?
2
8. b) ii) What was the date of the last application?
17-JUL-17
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?
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)
Minor
13. Please provide supplemental information here