31 Salem Street - Street File (4) CA,Q
1CITY OF SALEM, MASSACHUSETTS
l
_ l BOARD OF HEALTH
KIMBERLEY DRISCOLL 120 WASHINGTON STREET,4T'FLOOR
MAYOR TEL.(978)741-1800
FAX(978)745-0343
LARRY RAMDIN,RS/REHS,CHO,CP-FS LRAMDIN(&SALEM.COM
HEALTH AGENT
COMPLAINT INTAKE FORM
Date: Zr I Time: Received By: DL)A- ru
Complaint Number: 0553
Complainant \ Lnouk:5
Address: �j � ��1 Phone:
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Investigated By: Date:
Property Owner/Occupant Name Telephone#: