173 LAFAYETTE STREET - HOUSING COMPLAINT i � 1
CITY OF SALEM, MASSACHUSETTS
;<.> .,.
BOARD OF HEALTH
KIMBERLEY DRISCOLL 120 WASHINGTON STREET,4"'FLOOR
MAYOR TEL.(978)741-1800
-•• LARRY RAMDEQ,RS/REHS,CHO,CP-FS
L MDIN@ AL EM.00M
HEALTH AGENT
COMPLAINT INTAKE FORM
Date: Time: Received By:
Complaint Number: 2050
Complainant
Address: Phone:
Investigated By: Date:
Property Owner/Occupant Name Telephone#: