12 POPE STREET - STREET FILE (2) a
CITY OF SALEM, MASSACHUSETTS
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 LRAMDINCU)SALEM.COM
HEALTH AGENT
COMPLAINT INTAKE FORM
Date: r Time: �; �(���, Received By:�
Complaint Number: 1480
Complainantp
Address: Phone:Z— � _ 3'!Ain )N�4t _
'�
Y . .j
�F-
S e l e-
ttsan Ya-m °— 3o4- T- pi, �
Investigated By: Date:
Property Owner/Occupant Name Telephone#:
W -W 'ZZtvj fop tU(JAk( gfF to iMQ.ke reow 6��
wrx,A,gv,,e W, , n <(::&d i' ,scat;, ape Will
(c&