JACKSON STREET - RODENT COMPLAINT a
CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
KIMBERLEY DRISCOLL 120 WASHINGTON STREET,4T'FLOOR
TEL.(978)741-1800
(' \ MAYOR FAx(978)745-0343
LARRY RAMDIN,RS/REHS,CHO,CP-FS LRAMDINCa-,SALEM.COM
HEALTH AGENT
COMPLAINT INTAKE FORM
Date: I j �_� r7 Time:° Received By:
Complaint Number: 2001 _
Complainant
Address: i�1�:� �j Phone:
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Investigated By: Date:
Property Owner/Occupant Name Telephone #: