12 OSBORNE STREET - TRASH COMPLAINT rn kart' CITY OF SALEM,MASSACHUSETTS
:. r�' BOARD OF HEALTH
Ll.
KIMBERLEY DRISCOLL 120 WASHINGTON STREET,4TH FLOOR
MAYOR nL.(978)741-1800
FAX(978)745-0343
LARRY RAMDIN,RS/REHS,CHO,CP-FS LRAMDINra!SALEM.COM
HEALTH AGENT
COMPLAINT INTAKE FORM
Date: Time: Received By:
Complaint Number: 2172
Complainant __ _
Address: Phone:
Investigated By: Date:
Property Owner/Occupant Name Telephone #: