5 CHASE STREET - HOUSING COMPLAINT (2) r. , ! CITY OF SALEM,MASSACHUSETTS
>,,:, -�. BOARD OF HEALTH
MMBERLEY DRISCOLL 120 WASHINGTON STREET,4T'FLOOR
MAYOR (978)741-1800 FAX
FAx(978)745-0343343
LARRY RAMDIN,RS/REHS,CHO,CP-FS LRAMDIN(&SALEM.COM
HEALTH AGENT
COMPLAINT INTAKE FORM
Date: Time: Received By-
Complaint Number: 2122
Complainant
Address: Phone:
Investigated By: _ _ Date:
Property Owner/Occupant Name Telephone #:
I. y - C) %(Al L�