3 WISTERIA STREET - TRASH COMPLAINT (2) a
CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
KIMBERLEY DRISCOLL 120 WASHINGTON STREET,4"'FLOOR
MAYOR TEL.(978)741-1800
` FAX(978)745-0343
LARRY RAMDIN,RS/REHS,CHO,CP-FS LRAMDINra)SALEM.COM
HEALTH AGENT
COMPLAINT INTAKE FORM
Date: 1 2 t% ' r1 Time: Received By:
Complaint Number: 2010
Complainant
-r
Address: Phone:
Investigated By: Date:
Property Owner/Occupant Name Telephone#: