117 LAFAYETTE STREET - HOUSING COMPLAINT i
ITY OF SALEM, MASSACHUSETTS
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BOARD OF HEALTH
KIMBERLEY DRISCOLL _ 120 WASHINGTON STREET,4TH FLOOR
MAYOR 978)741-1800 FAX((( (((
FAx 978)745-0343343
LARRY RAMDIN,RS/REHS,CHO,CP-FS LRAMDINn.SALEM.COM
HEALTH AGENT
COMPLAINT INTAKE FORM
Date: Time:l/ l Received By:
Complaint Number: 2187
Complainant V7
Address: �'�" - =fir Phone:
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Investigated By: Date:
Property Owner/Occupant Name Telephone #:
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