38 RAYMOND ROAD - STREET FILE CITY OF SALEM,MASSACHUSETTS
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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 LRAMDINO SALEM.COM
HEALTH AGENT
COMPLAINT INTAKE FORM
Date: Time: l Q Received By-.,,*�avz—
Complaint Number: 1406
Complainant �1
Address: Phone:c2 V �0 7- in
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Investigated By: Date:
Property Owner/Occupant Name Telephone #: