81 CONGRESS STREET - TRASH COMPLAINT „�EA1 CITY OF SALEM,MASSACHUSETTS
�� BOARD OF HEALTH
KIMBERLEY DRISCOLL 120 WASHINGTON STREET,e”FLOOR
MAYOR TEL.(978)741-1800
FAx(978)745-0343
LARRY RAMDTN,RS/REHS,CHO,CP-FS LRAMDTN(d)SALEM.COM
HEALTH AGENT
COMPLAINT INTAKE FORM
Date: Time: Received By: - -
Complaint Number: 2387
Complainant
Address: Phone:
Investigated By: Date: -
Property Owner/Occupant Name _ Telephone #: