31 Salem Street - Street File (7) / S
,. CITY OF SALEM, MASSACHUSETTS
l 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 LRAMDIN R SALEM.COM
HEALTH AGENT
COMPLAINT INTAKE FORM
JP- r-
Date: �,� �; Time: h Received By: �
Complaint Number: 0580
Complainant Sar °
Address: �(�� ' � Phone:
Investigated By: Date: - - )
Property Owner/Occupant Name Telephone#: