5 CHASE STREET - HOUSING COMPLAINT nNUl+i �\
=r � 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 LRAMDIN_y-SALEM.COM
HEALTH AGENT
COMPLAINT INTAKE FORM
Date: Time: Received By:
Complaint Number: 2112
Complainant ,}� �- %✓ �S
Address: 1. !!, !� �.-r,; ! % Phone:
Investigated By:
Date: ` 1
Property Owner/Occupant Name Telephone #:
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