10 HOWARD STREET - HOUSING COMPLAINT -aa CITY OF SALEM, MASSACHUSETTS
�„�� BOARD OF HEALTH
KIMBERLEY DRISCOLL 120 WASHINGTON STREET,4T"FLOOR
j MAYOR TEL.(978)741-1800
FAx(978)745-0343
LARRY RAMDIN,RS/REHS,CHO,CP-FS LRAMDIN(9iSALEM.COM
HEALTH AGENT
COMPLAINT INTAKE FORM
Date: " ' Time: ^1_ Received By:
Complaint Number: 2000
Complainant
Address: C_i Phone: f I I) 232`(J y�2
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Investigated By: _ Date:
Property Owner/Occupant Name Telephone #: