Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2012-5456

2. Registrant Information.

Registrant Reference Number: x

Registrant Name (Full Legal Name no abbreviations): x

Address: x

City: x

Prov / State: xx

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: QUEBEC

6. Date incident was first observed.

22-MAY-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.       PMRA Submission No.       EPA Registration No.

Product Name:

• Active Ingredient(s)
  • ATRAZINE (PLUS RELATED ACTIVE TRIAZINES)
  • CARBARYL
  • CLOTHIANIDIN
  • PYRIMETHANIL
  • S-METOLACHLOR AND R-ENANTIOMER
  • THIAMETHOXAM

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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: Agricultural-Outdoor/Agricole-extérieur

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

Le rucher est immediatement entoure (moins de 50 metres) de terres agricoles cultivant principalement du mais et du soya. Ces deux cultures ont ete recemment semees ou le seront dans les prochains jours. Methode d application principale semoir pneumatique.

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

Terr. Invrtbrt-Honey Bee/Inv.Ter-Abeille

2. Common name(s)

Honey bee

3. Scientific name(s)

Apis mellifera

4. Number of organisms affected

200

5. Description of site where incident was observed

Fresh water

Terrestrial

Agricultural

Salt Water

6. Check all symptoms that apply

Abnormal behavioural effects

Death

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

Accumulation de mortalite devant l entree de la ruche. Activite normale a lentree, mais abeilles tres agressives. Quelques abeilles sont desorientees et lethargiques. Mort. Numero dechantillon analyse par le MAPAQ: 70399301 0,011 mg g de Clothianidine et 0,001 mg g de Thiamethoxame Contenait aussi 0,001 mg g de Pyrimethanil, 0,002 mg g de Metolachlore, 0,021 de Carbaryl et 0,001 mg g d Atrazine

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

Unknown

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?

No

9. b) Up to 3 days after application?

No

10. a) Was there a buffer zone?

No

10. b) What type?

Terrestrial

10. c) What was the size of the buffer zone?

11. a) Were environmental samples collected and analysed?

Yes

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