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The personal information on this form is collected under the authority of the Health Protection and Promotion Act and will be used for the administration of Public Health programs. Any questions about the collection of this information should be directed to the manager of Environmental Health, South East Health Unit, 179 N Park St., Belleville, Ontario, K8P 4P1, 613-966-5500 or 1-800-267-2803, ext. 677.