Health Canada
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Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2019-5325
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.
24-SEP-19Product 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: Mothballs
- Active Ingredient(s)
- NAPHTHALENE
7. b) Type of formulation.
Other (specify)
mothballsApplication Information
8. Product was applied?
Unknown
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).
The following was reported: I found mothballs in little paper packets, which looked like candy, on my side yard. My next door neighbour complained about my plants and trees on a previous occasion. The mothballs were found on my property, next to their concrete walkway. I threw all mothballs out of my yard onto their walkway and took a picture.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)
Beech tree, Cedar
3. Scientific name(s)
Fagus, Cedrus
4. Number of organisms affected
3
5. Description of site where incident was observed
Fresh water
Terrestrial
Residential
Salt Water
6. Check all symptoms that apply
Abnormal leaf discoloration
Death
7. Describe symptoms and outcome (died, recovered, etc.).
I have about four 2 year old trees or so that are slowly dying...it started a few moths after I planted them, very much to dislike of my neighbour. I went to check on my beech trees and hostas on my side yard. I noticed the trees started getting brown leaves, just recently, in the last month or two. The one cedar (which I had for about 9 years) is almost completely dead.
8. a) Was the incident a result of (select all that apply)
Unknown
8. b) i) How many times has the product been applied this year?
Unknown
8. b) ii) What was the date of the last application?
Unknown
9. Did it rain
9. a) During application?
Unknown
9. b) Up to 3 days after application?
Unknown
10. a) Was there a buffer zone?
Unknown
10. b) What type?
10. c) What was the size of the buffer zone?
11. a) Were environmental samples collected and analysed?
Unknown
