1A BELLEAU ROAD - NUISANCE COMPLAINT r1716)
CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
KIMBERLEY DRISCOLL 120 WASHINGTON STREET,4T'FLOOR
J^�, MAYOR TEL.(978)741-1800
FAX(978)745-0343
LARRY RAMDIN,RS/REHS,CHO,CP-FS LRAMDBVQSALEM.COM
HEALTH AGENT
COMPLAINT INTAKE FORM
Date: Time: Received By:
Complaint Number: 2013
Complainant
"4!
Address: - Phone:
Investigated By: Date:
Property Owner/Occupant Name Telephone #: