28 GOODHUE STREET - STREET FILE 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 LRAMDIN ai SALEM.COM
HEALTH AGENT
COMPLAINT INTAKE FORM I
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Date: Time: Received By: 0 16
Complaint Number: 1476
Complainant
Address: ailPhone:41 ,Z�0
Investigated By: Date:
Property Owner/Occupant Name Telephone #:
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