12 POPE STREET - HOUSING COMPLAINT ! CITY OF SALEM,MASSACHUSETTS
ti3 BOARD OF HEALTH
KIMBERLEY DRISCOLL 120 WASHINGTON STREET,4T"FLOOR
MAYOR TEL.(978)741-1800
FAx(978)745-0343
LARRY RAMDIN,RS/REHS,CHO,CP-FS LRAMDfNQSALEM.COM
HEALTH AGENT
COMPLAINT INTAKE FORM
Date: 1 q Time: Received By: _
Complaint Number: 2334
Complainant
Address: `� ^ -44--AI D 7_ Phone:_ _
Investigated By: ( Date:
Prop Owner/Occupant Name f Telephone