88 ESSEX STREET - HOUSING COMPLAINT n CITY OF SALEM,MASSACHUSETTS
F BOARD OF HEALTH
KIMBERLEY DRISCOLL 120 WASHINGTON STREET,4"FLOOR
MAYOR (978)741-1800 FAX
FAx(978)745-0343343
LARRY RAMDIN,RS/REHS,CHO,CP-FS LRAMDIN.'SALEM.COM
HEALTH AGENT
COMPLAINT INTAKE FORM
Date: Time: Received By:
Complaint Number: 2292
Complainant
Address: t _ % ! ' Phone:
Investigated By: _ Date:
Property Owner/C'ccupant Name _ Telephone#: