Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2015-7000

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-MAY-13

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. 27833      PMRA Submission No.       EPA Registration No.

Product Name: Callisto 480SC Herbicide

• Active Ingredient(s)
  • MESOTRIONE

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

Product Name: Primextra

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

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7. b) Type of formulation.

Application Information

8. Product was applied?

Yes

9. Application Rate.

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

Site: Agricultural-Outdoor/Agricole-extérieur

Préciser le type: Corn

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

Corn field about 100 ft (30 metres) west of greenhouse with tobacco seedlings was sprayed with Calisto and Primextra on Monday or Tuesday May 13 or 14th. Caller believes that soil from corn field was blown around during strong wind on Wednesday/Thrusday last week. The soil and attached pesticide entered greenhouse through ridge vent and impacted the tobacco seedlings. XXXXX does not believe that actual spray drift entered the greenhouse because the vents were closed at the time due to cooler temperatures.

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)

tobacco

3. Scientific name(s)

Unknown

4. Number of organisms affected

Unknown

5. Description of site where incident was observed

Fresh water

Terrestrial

Agricultural

Salt Water

6. Check all symptoms that apply

Epinasty (leaf wilt)

Visible injury ( eg. chlorosis, necrosis, bleaching)

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

The damage to the tobacco seedlings is described as "leaves going white, hearts cupping and turning yellow".

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