173 Lafayette Street Apt. 1 Complaint 7-28-2019 /� °1'ea
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CITY OF SALEM,MASSACHUSETTS
0.""y,�r=�` BOARD OF HEALTH
KIMHERLEY DRISCOLL 120 WASHINGTON STREET,4T'FLOOR
MAYOR TEL.(978)741-1800
FAx(978)745-0343
LARRY RAMDIN,RS/REHS,CHO,CP-FS LRAMDIN&.SALEM.COM
HEALTH AGENT
COMPLAINT INTAKE FORM
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Date: Time: y Received By: vo.
Complaint umber: 2511
Complainant
Address: ' — f �,9, Phone:
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Investigated By: _ Date:
Property Owner/Occupant Name__ _Telephone #: