10-12 FIRST STREET - SANITARY COMPLAINT a
CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
KIMBERLEY DRISCOLL 120 WASHINGTON-STREET,4r"FLOOR
MAYOR TEL.(978)741-1800
FAX(978)745-0343
LARRY RAMDIN,RS%REHS,CHO,CP-FS LRAMDINC&ISALEM.COM
HEALTH AGENT
COMPLAINT INTAKE FORM
Date: Time: _ Received By:
Complaint Number: 1980
Complainant
Address: 'I Phone:
Investigated By: Date:
Property Owner/Occupant Name Telephone #: