LEAVITT STREET - TRASH COMPLAINT 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 LRAMDINr?SALEM.COM
HEALTH AGENT
COMPLAINT INTAKE FORM
Date: yy Time: Received By:
Complaint Number: 2228
Complainant �� / i
Y
Address: � l '"7 � ;T,� i yr �7 -., ;.- �, Phone:
Investigated By: r'. Date: -
Property Owner/Occupant Name Telephone #: _ __