5 GARDNER STREET - TRASH COMPLAINT a
CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
KIMBERLEY DRISCOLL 120 WASHINGTON STREET,4 "FLOOR
MAYOR TEL.FAx(978)741-1800
FAx(978)745-0343343
LARRYRAMDIN,RS/REHS,CHO,CP-FS LRAMDINCt%SALEM.COM
HEALTH AGENT
COMPLAINT INTAKE FORM
Date: Time: Received By:
Complaint Number: 2173 1
Complainant
Address: E: Phone: "
Investigated By: _ Date: _
Property Owner/Occupant Name Telephone #: