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Personal information on this form is collected under the authority of the Health Protection and Promotion Act S.O. 1983, c.10 and will be used for the administration of public health programs. Any questions about the collection of this information should be directed to the director of Environmental Health, KFL&A Public Health, 221 Portsmouth Avenue, Kingston, Ontario K7M 1V5, 613-549-1232 or 1-800-267-7875, ext. 1243.
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