201 WASHINGTON STREET - HOUSING COMPLAINT u r._\
n' CITY OF SALEM,MASSACHUSETTS
`'` BOARD OF HEALTH
KIMBERLEY DRISCOLL 120 WASHINGTON STREET,4T'FLOOR
MAYOR TEL.(978)741-1800
FAx(978)745-0343
LARRY RAMDIN,RS/REHS,CHO,CP-FS LRAMD[N[+SALEM.COM
HEALTH AGENT
COMPLAINT INTAKE FORM
Date: Time: Received By:
Complaint Number: 2016
Complainant
Address: Phone:
Investigated By: _ _ Date:
Property Owner/Occupant Name Telephone #: __