214 LAFAYETTE STREET - TRASH COMPLAINT a
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 LRAMDP.'A�SALEM.COM
HEALTH AGENT
COMPLAINT INTAKE FORM
Date: ;� �/, / Time: Received By:
Complaint Number: 2004
Complainant A
A- �
Address: Phone:
44
12a �J—AA< )JV4 124:32 1 f
Investigated By: Date: r l
Property Owner/Occupant Name _ Telephone #: