40 School Street Complaint 5-21-2018 �aNU(tq
�- 4 CITY OF SALEM,MASSACHUSETTS
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�'�'��- BOARD OF HEALTH
KIMBERLEY DRISCOLL 120 WASHINGTON STREET,4:"FLOOR
MAYOR TEL.(978)741-1800
FAx(978)745-0343
LARRY RAMDIN,RS/REHS,CHO,CP-FS LRAMDIN alSALEM.COM
HEALTH AGENT
COMPLAINT INTAKE FORM
Date: _ �'I Time: U`�o Received By: C�� -�
Complaint Number: 2132
Complainant Y a
Address: j 'l. l T Phone:
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Investigated By: _ _ _ Date:
Property Owner/Occupant Name Telephone #: