12 FIRST STREET - STREET FILE i
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CITY OF SALEM, MASSAC14USETTS
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 LRAMDINriVSALEM.COM
HEALTH AGENT
COMPLAINT INTAKE FORM
Date: Time: 4 Received By:
Complaint Number: 1405
Complainant [ }1� l�Gt k Le�j,'Vo;r.
'Address: aL r Phone:
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Investigated By: Date:
Property Owner/Occupant Name Telephone #: