Incident Report

Subform I: General Information

1. Report Type.

Update the report

Incident Report Number: 2012-1812

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)

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PMRA Registration No. 27770      PMRA Submission No.       EPA Registration No.

Product Name: POLYDEX BACTERIOSTATIC ALGAECIDE MC

• Active Ingredient(s)
  • COPPER AS ELEMENTAL (PRESENT AS COPPER SULPHATE)

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7. b) Type of formulation.

Application Information

8. Product was applied?

Yes

9. Application Rate.

450

Units: L

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

Site: Pub. Area - Outdoor/Zone publique - ext

Préciser le type: lake

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

4 hectare treatment area out of an approximately 16 hectare lake. 450 L. Application rate of 1/60,000. Algae. Ontario Pesticide Permit # () Applied April 16, 2012 to the large lake.Reported to the MoE, (city) Office, April 21 2012. MoE were to take samples.

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-Non-schooling/Poisson-Autre poisson

2. Common name(s)

Unknown

3. Scientific name(s)

Unknown

4. Number of organisms affected

40

5. Description of site where incident was observed

Fresh water

Lake

Terrestrial

Salt Water

6. Check all symptoms that apply

Death

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

4 hectare treatment area out of an approximately 16 hectare lake. 450 L. Application rate of 1/60,000. Algae.

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?

Unknown

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

Unknown

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?

Unknown

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