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Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2015-7002
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.
23-MAY-13Product 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.
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 that his neighbour applied roundup twice along the edge of the property and along the boulevard (Town property)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)
grass
3. Scientific name(s)
Unknown
4. Number of organisms affected
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.).
Caller reports that his grandfather's neighbour has killed all the grass along the side of the house with Roundup and that the material soaked into a drainage area that drains to the back of the property, killing grass, a hedge and the tree closest to the house on his grandfather's property.
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?
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
Subform IV: Environment (includes plants insects and wildlife)
1. Type of organism affected
Trees or shrubs / Arbre ou arbuste
2. Common name(s)
Unknown
3. Scientific name(s)
Unknown
4. Number of organisms affected
5. Description of site where incident was observed
Fresh water
Terrestrial
Residential
Salt Water
6. Check all symptoms that apply
Visible injury ( eg. chlorosis, necrosis, bleaching)
7. Describe symptoms and outcome (died, recovered, etc.).
Caller reports that his grandfather's neighbour has killed all the grass along the side of the house with Roundup and that the material soaked into a drainage area that drains to the back of the property, killing grass, a hedge and the tree closest to the house on his grandfather's property. There are three trees (cedar hedge?) in line with the underground eaves drain. The middle tree was observed to be stressed (brown). The trees on either side appeared to be ok.
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?
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
