3 WISTERIA STREET - TRASH COMPLAINT a
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 LRAMDINCWSALEM.COM
HEALTH AGENT
COMPLAINT INTAKE FORM
Date: Time: / ,�, Received By:
Complaint Number: 2022
Complainant
Address: Phone:
Investigated By: Date: -
Property Owner/Occupant Name _ Telephone #: