276 Washington Street 1st Floor Complaint 10-2-2019 ���pWll
r
CITY OF SALEM, MASSACHUSETTS
r�<.�;��� BOARD OF HEALTH
KFMBERLEY DRISCOLL 120 RTASHINGTON STREET,4"FLOOR
MAYOR TEL.(978)741-1800
FAx(978)745-0343
LARRY RAMDIN,RS/REHS,CHO,CP-FS LRAMDIN(@,,SALF,M.COM
HEALTH AGENT
COMPLAINT INTAKE FORM
Time:Date:
�— Received By
0219 - - F-1
Complaint Number: 2598
Complainan _ � I 1rAj—) �
Address: Phone*
DCAD
kzw
Investigated )—
Property Owner/Occupant Name _ __ _Telephone#: _ _ --