ORD STREET - TRASH COMPLAINT (, =i CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
KIMBERLEY DRISCOLL 120 WASHINGTON STREET,4T'FLOOR
MAYOR A (978)741-1800 FAX
A (978)745-0343343
LARRY RAMDIN,RSiREHS,CHO,CP-FS LRAMDINC2 SALEM.COM
HEALTH AGENT
COMPLAINT INTAKE FORM
Date: Time: �2 J�D Received By:
Complaint Number: 1754
Complainant
Address:}�, l_ ,�� Phone: _ 2
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Investigated By: / �? Date:
Property Owner/Occupant Name Telephone #:
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