26 NEW DERBY STREET - TRASH COMPLAINT CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
KIMBERLEY DRISCOLL 120 WASHINGTON STREET,4TH FLOOR
MAYOR A (978)741-1800 FAx
A (978)745-0343343
LARRY RAMDIN,RS/REHS,CHO,CP-FS LRAMDIN6iSALEM.COM
HEALTH AGENT
COMPLAINT INTAKE FORM
Date: Time: Received By-
Complaint Number: 2157
Complainant
Address: -r,� 71/7( , -: .1 f ',� i Phone: -- —
Investigated By: i P , , Date:
Property Owner/Occupant Name - Telephone