316 LAFAYETTE STREET - HOUSING COMPLAINT i'mmrq\
a m CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
�+ KIMBERLEY DRISCOLL 120 WASHINGTON STREET,4TH FLOOR
1 MAYOR TEL.(978)741-1800
1 / FAX(978)745-0343
-_ LARRY RAMDIN,RS/REHS,CHO,CP-FS LRAMDINOd ISALEM.COM
HEALTH AGENT
COMPLAINT INTAKE FORM
Date: ,( Time: Received By:
Complaint Number: 2311
Complainant
Address: Phone:TS Z 5Q2
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Investigated By: _ Date:
Property Owner/Occupant Name Telephone #: