14 & 16 Hazel Street Complaint 7-24-2018 z. `. � CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
KIMBERLEY DRISCOLL 120 WASHINGTON STREET,4TH FLOOR
r- MAYOR TEL.(978)741-1800
FAX(978)745-0343
LARRY RAMDIN,RS/REHS,CHO,CY-FS LRAMDINf¢SALEM.COM
HEALTH AGENT
COMPLAINT INTAKE FORM
Date: Time: t Received By: =?
Complaint Number: 2197
Complainant
Address: Phone: Q �Pf� `
Investigated By: _ Date:
Property Owner/Occupant Name ___ Telephone #: