5 HILTON STREET - SANITARY COMPLAINT -rN
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CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
KIMBERLEY DRISCOLL 120 WASHINGTON STREET,4T'FLOOR
MAYOR TEL.(978)741-1 goo
FAX(978)745-0343
LARRY RAMDFN,RS/REHS,CHO,CP-FS LRAMDfN(WSALEN1.COM
HEALTH AGENT
COMPLAINT INTAKE FORM
Date: Time: Received By
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Complaint Number: 1763
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Complainant Deb Y-0- &J-1,11LK e--&t,/ P-r V L/5 k,,
Address: S+rret Phone:
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Investigated By: Date:
Property Owner/Occupant Name-- Telephone #: