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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2015-4642

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.

14-JUN-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: Roundup

  • Active Ingredient(s)
    • GLYPHOSATE (PRESENT AS ISOPROPYLAMINE SALT OR ETHANOLAMINE SALT)

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).

Caller reported a complaint that their neighbour is spraying round up to their property. It was seen today at 11:30 and has been ongoing since weeds have been growing this season. property is being impacted as plants near the property border are dying. The caller is also concerned of health impacts to their family. Caller also concerned of run off to storm sewers. there was no obvious signs of impact - eg wilted/dead grass or vegetation on the site or on the boarding City property. The property line and the houses are very close. Aside, it has rained extensively since this complaint.

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)

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

Death

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

propertyis being impacted as plants near the property border are dying.On observation, there was no obvious signs of impact - eg wilted/dead grass or vegetation on the site or on the boarding City property. The property line and the houses are very close. Aside, it has rained extensively since this complaint. he infromed me that he can smell chemicals from the neighbours grass/garden maintenance and he believes that they use pesticides from the usa - though he has not confirmed this. He said that the chemicals smell really bad and they can't go in their back yard when the chemicals have been sprayed.

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