SALEM WILLOWS - STREET FILE SaIern VVi IIows ('tv1sc)
3+, / CITY OF SALEM,MASSACHUSETTS
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 LRAMDINQSALEM.COM
HEALTH AGENT
COMPLAINT INTAKE FORM
Date: Time: /a Received By:
Complaint Number: 1714
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Investigated By: Date:
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Property Owner/Occupant Name 01_ �r —Telephone #:
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