12 Moulton Avenue Complaint 8-9-2019 a
CITY OF SALEM,MASSACHUSETTS
BOARD OF HEALTH
r� KIMBERLEY DRISCOLL 120 WASHINGTON STREET,4T"FLOOR
MAYOR TELL.(978)741-1800
FAx(978)745-0343
LARRY RAMDIN,RS/REHS,CHO,CP-FS LRAMDINna,SALEM.COM
HEALTH AGENT
COMPLAINT INTAKE FORM
Date: Time: �� Received By:
Complaint Number: 2534
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Address: Phone:
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Investigated By: Date:
Property Owner/Occupant Name Telephone #: