FORT AVENUE - POWER PLANT COMPLAINT CITY OF SALEM,MASSACHUSETTS
rr ? BOARD OF HEALTH
KIMBERLEY DRISCOLL 120 WASHINGTON STREET,4"FLOOR
MAYOR TEL.(978)741-1800
FAx(978)745-0343
-' LARRY RAMDIN,RS/REHS,CHO,CP-FS LRAMDIN(a1SALEM.COM
HEALTH AGENT
COMPLAINT INTAKE FORM
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Date: Time: _ Received By: _
Complaint Number: 2040
Complainant
Address: Phone:
Investigated By: Date:
Property Owner/Occupant Name __ Telephone #: