12 POPE STREET - STREET FILE �'1 CITY OF SALEM, MASSACHUSETTS
`�_'Y 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 LRAMDINtIP.SALEM.COM
HEALTH AGENT
COMPLAINT INTAKE FORM
Date: 0 22 4 1-f Time: Ca kj Received By: t-(,'a s.-Afl, u
Complaint Number: 0879
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CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
KIMBERLEY DRISCOLL 120 WASHINGTON STREET,4TH FLOOR
I MAYOR TEL.(978)741-1800
FAx(978)745-0343
LARRY RAMDIN,RS/REHS,CHO,CP-FS LRAMDINCd'SALEM.COM
HEALTH AGENT
COMPLAINT INTAKE FORM 1
Date: Time: }� OL-,i\ Received By:
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Complaint Number: 0862
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Address: Z.1 Phone:
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