Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2015-7006

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.

20-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.       PMRA Submission No.       EPA Registration No.

Product Name: Killex

• Active Ingredient(s)
  • 2,4-D (PRESENT AS AMINE SALTS : DIMETHYLAMINE SALT, DIETHANOLAMINE SALT, OR OTHER AMINE SALTS)
  • DICAMBA (PRESENT AS ACID, AMINE SALT, ESTER, POTASSIUM SALT, OR SODIUM SALT)
  • MECOPROP-P (PRESENT AS DIMETHYLAMINE SALT)

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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: 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).

a woman called to report that her next door neighbour sprayed Killex in her yard 2 days ago and killed her butterfly bushes.

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

Trees or shrubs / Arbre ou arbuste

2. Common name(s)

butterfly bush

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.).

Overspray by neighbour killed bushes.

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