18 Chase Street Complaint 11-4-2019 �nu
n CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
—_ KIMBERLEY DRISCOLL 120 WASHINGTON STREET,4T"FLOOR
MAYOR TEL.(978)741-1800
FAX(978)745-0343
LARRY RAMDIN,RS/REHS,CHO,CP-FS LRAMDINOSALEM.CQM
HEALTH AGENT
COMPLAINT INTAKE FORM
Date: \ Time: 10A Received By:
Complaint Number: 2620
Complainant
Address: Phone: "
-�7—v J h
investigated By: _ Date:
Property Owner/Occupant Name___ _ ___Telephone #: