16 SUMMIT STREET - NUISANCE COMPLAINT �r,• ,, CITY OF SALEM,MASSACHUSETTS
J~ BOARD OF HEALTH
KIMBERLEY DRISCOLL 120 WASHINGTON STREET,4TH FLOOR
MAYOR FAX(978)741-1800
FAx(978)745-0343343
LARRY RAMDIN,RS/REHS,CHO,CP FS LRAMDIN:a'SALEM.COM
HEALTH AGENT
COMPLAINT INTAKE FORM
Date: Time: Received By:
Complaint Number: 2293
Complainant
Address: Phone:
Investigated By: - Date:
Property Owner/Occupant Name_ _ Telephone