3 WAITE STREET - STREET FILE CITY OF SALEM,MASSACHUSETTS
.0 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 LRAMDINra'SALEM.COM
HEALTH AGENT
COMPLAINT INTAKE FORM
Date: 14, Time: /C M Ow- Received BY �AL(ct/J
Complaint Number: 0577
Complainant PIX
Address: 4 Phone:
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Investigated By:—)I Date:
Property Owner/Occupant Name Telephone#: