4 Lee Fort Terrace Complaint 10-22-2019 NUIT�
(as, _ CITY OF SALEM, MASSACHUSETTS
�.Q?�„....� BOARD OF HEALTH
KIMBER1,EY DRISCOLL 120 WASHINGTON STREET,4T'FLOOR
MAYOR TEL.(978)741-1800
FAX(978)745-0343
LARRY RAMDIN,RS/REHS,CHO,CP-FS LRAMDiNNaSALEM.COM,
HEALTH AGENT
�y COMPLAINT INTAKE FORM
Date: I�2 ) "1 Time: 2 Received By:
Complaint Number: 2618
Complainant
Address: G-I LAP �P13'►�QC,2� Phone:
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Investigated By: _ Date:
Property Owner/Occupant Name__ _Telephone #: