12 FRANKLIN STREET - ILLEGAL DUMPING COMPLAINT /�:inwrq,�.
(, r CITY OF SALEM, MASSACHUSETTS
,�, :
BOARD OF HEALTH
KIMBERLEY DRISCOLL 120 WASHINGTON STREET,47"FLOOR
MAYOR TEL.(978)741-1800
_ FAx(978)745-0343
��- LARRY RAMDEV,RS/REHS,CHO,CP-FS LRAMDINASALEM.COM
HEALTH AGENT
COMPLAINT INTAKE FORM
Date: l Time: Received By: _
Complaint Number: 2107
Complainant _
Address: Phone:
Investigated By: _ Date:
Property Owner/Occupant Name Telephone #: