26 CROSS STREET - HOUSING COMPLAINT (j CITY OF SALEM, MASSACHUSETTS
��r;e;. BOARD OF HEALTH
KIMBERLEY DRISCOLL 120 WASHINGTON STREET,4T"FLOOR
MAYOR (978)741-1800 FAX
10 FAx(978)745-0343343
LARRY RAMDIN,RS/REHS,CHO,CP-FS LRAMDINOaSALEM.COM
HEALTH AGENT
COMPLAINT INTAKE FORM
Date: Time: Received By:
Complaint Number: 2092
Complainant -
Address: Phone:
_ .l
Investigated By: Date: _
Property Owner/Occupant Name Telephone #: -