Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2015-7009

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.

10-JUN-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: 2,4-D

• Active Ingredient(s)
  • 2,4-D (PRESENT AS ACID)

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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

Préciser le type: lawn

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

Caller reports 2,4-D damage to his grapes. He has 100 acres of grapes, alleges that neighbour directly across the street applied 2,4-D to his lawn for weeds and drift impacted about 3 acres of grapes, on the SW corner of his farm.

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)

grapes

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

Deformities

Epinasty (leaf wilt)

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

Caller farms 56 acres of Concord and 44 acres of Niagara grapes. Damage noted on June 10. The leaves are curling up and deformed looking. The vines closest to the road, directly across from XXX XXXXX St. appeared to show the greatest effects. Grapes further back from the road showed decreasing levels of symptoms. Grapes further along XXXXX St. (northeast of affected area) show no visible physical symptoms of phenoxy herbicides.

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