HAZEL STREET - TRASH COMPLAINT • ;.rcn.wraa
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CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
KIMBERLEY DRISCOLL 120 WASHINGTON STREET,4TH FLOOR
MAYOR TEL.(978)741-1800
\ FAx(978)745-0343
~ LARRY RAMDIN,RS/REHS,CHO,CP-FS LRAMDIN(@SALEM.COM
HEALTH AGENT
COMPLAINT INTAKE FORM
Date: � Time: Received By:
Complaint Number: 1901
Complainant
Address: G,Z r S) Phone:
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Investigated By: Date: CsZ
Property Owner/Occupant Name Telephone #: