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11 Church Street #603 Complaint 5-29-2018 0CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH KIMBERL.EY DRISCOLL 120 WASHINGTON STREET,e'FLOOR MAYOR TEL.(978)741-1800 FAX(978)745-0343 LARRY RAMDIN,RS/REHS,CHO,CP-FS LRAmDrN@sALFm.com HEALTH AGENT COMPLAINT INTAKE FORM p Date: 5V2—ql 201 Time: Received By: .! Complaint Number: 2135 Complainant_—D Address: Phone: q 91— ®r/q 0 ! Qs--W1 g -LI SL 03 6�x r©81,0 Ls CL r ul ,ki a C0++1 L m ,,% L (: kOM 17 I23 r1 can 4 'd � r Investigated By: _ Date: Property Owner/Occupant Name_ Telephone#: _