5 SUMMIT STREET - HOUSING COMPLAINT CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
^ KIMBERLEY DRISCOLL 1201ATASHINGTON STREET,4'FLOOR
MAYOR FAX(978)741-1800
FAx]\ J (978)745-0343343
LARRY RAMDIN,RS/REHS,CHO,CP-FS LRAMDr.N(a SALHM.COM
HEALTH AGENT
COMPLAINT INTAKE FORM
Date: 2�f� Time: I_ - !! Received By: JWf1rV S
Complaint Number: 1779
Complainant
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Address: > �,,,m,,, 1 l e� - �- Phone:q`�/�-
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Investigated By: Date:
Property Owner/Occupant Name Telephone#: