28 BOW STREET - STANDING WATER COMPLAINT �iT
=1 CITY OF SALEM, MASSACHUSETTS
Vie'y, i
BOARD OF HEALTH
KIMBERLEY DRISCOLL 120 WASHINGTON STREET,4TE3 FLOOR
MAYOR TEL.(978)741-1800
FAX(978)745-0343
LARRY RA.MDI\,RS/REHS,CHO,CY-FS LRAMDP.-CWSALEM.COM
HEALTH AGENT
COMPLAINT INTAKE FORM
Date: Time: i ; �J�� l )�i Received By: IRA" j
Complaint Number: 1771
Complainant
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