127 CANAL STREET - HOUSING COMPLAINT /�oYwr
nr CITY OF SALEM, MASSACHUSETTS
����'=_" � BOARD OF HEALTH
KIMBERLEY DRISCOLL 120 WASHINGTON STREET,4T"FLOOR
MAYOR TEL.FAX(978)741-
1800
FAx(978)745-0343343
LARRY RAMDIN,RS/REHS,CHO,CP-FS LRAMDIN[a'SALEM.COM
HEALTH AGENT
COMPLAINT INTAKE FORM
Date: Time: Received By:
Complaint Number: 2344
Complainant
Address: Phone:
Investigated By: i Date: _
Property Owner/Occupant Name _ Telephone #: _