117 LAFAYETTE STREET - TRASH COMPLAINT -CITY OF SALEIVI,"MASSACHUSETTS
A1or " BOARD OF HEALTH
KIMBERLEY DRISCOLL 120 WASHINGTON STREET,4T"FLOOR
MAYOR TEL.FAx(978)741-1
800
FAx(978)745-0343343
LARRY RAMDIN,RS/REHS,CHO,CP-FS LRAMDIN[aiSALEM.COM
HEALTH AGENT
COMPLAINT INTAKE FORM
Date: Time: Received By:
Complaint Number: 2280
Complainant
Address: !,/_�Tl `r' Phone:
l '
Investigated By: Date:
Property Owner/Occupant Name Telephone#: