1A BELLEAU ROAD - NUISANCE COMPLAINT (2) _ GGNWT9�
;a� 4 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 LRAMDFNr&SALEM.COM
HEALTH AGENT
COMPLAINT INTAKE FORM
Date: Time: Received By: _ /i / 1 i
Complaint Number: 2006 {{
Complainant I ,
Address: ' r !� 1�� - , . Phone: -- - _--
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Investigated By: Date:
Property Owner/Occupant Name Telephone #: