JEFFERSON AVENUE - SANITARY COMPLAINT CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
ERLEY DRIS KIMB a COLL 120 WASIHN-GTON STREET,eH FLOOR
MAYOR TEL.(979)741-1800
FAX(978)745-0343
LARRY RAMDrN,RS/REHS,CHO,CP-FS LRAMDfN(&SALEM.COM
HEALTH AGENT
COMPLAINT INTAKE FORM
Date: Time: Received By:
Complaint Number: 1921
Complainant
Address: Phone:
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Investigated By: Date:
Property Owner/Occupant Name Telephone #: