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SENDER.- COMPLETE THIS SECTION COMPLETE THIS SECTION ON DELIVERY
A� Complete items 1,2,and 3. �Signature �
�ff Print your name and address on the reverse I 4j X ant
so that we can return the card to you. dresses
v Attach this card to the back of the mailpiece, B. Received b P tecelame) C, Date of Delivery
_ or on the front if space permits. � (r�
1. Article Addressed to: D. Is de"ry address different from item 17 13 Yes I
ar, If YES,enter delivery address below: p No )
Pa 1 & Shirley Gallo 1
C/& Marc D. Gallo I
9 Marion Road
Salem, MA 01970
i
IIIIIIIII IIIIIIIII II III . Type p Priority Me
0 Adult Service
❑Registered MailTIIII III I IN IIIIIIIIIII
❑Adult Signature Restricted Delivery ❑Registered Mail Resirloted I
DG ❑Certified Mails Delivery
9590 9403 0431 5163 4443 74 CI CergHed Mail Regtricted Delivery ❑Retum Receipt for
❑collect on Delivery Merchandise
2. Article Number(Trap.sfer from service Ishall•: U;collect on Del}very Restricted Delivery 4 Signature CoMimnationn"
❑Signature Confirmation
7013 3020 0002 1522 7986 `estricted Delivery Restricted Delivery
PS Form 3811,April 2015 PSN 7530-02-000-9053 Domestic Return Receipt I
UNITED STA7 IftVICE First-Class Mail
• �� • . S postage&Fees Paid
USP
Permit No.G-10
5 :Please print your name,address, and ZIP+4®in this box*
Salem
Bard of Health
gWashington Street 4til-Floor
em, MA 01970
SPS TRACKING#
d'—35 C: -
959� 9433 1431 5163 4443 74
i
CITY OF SALEM, MASSACHUSETTS
a BOARD OF HEALTH
KIMBERLEY DRISCOLL 120 WASHINGTON STREET,4TH FLOOR
MAYOR TEL.(978)741-1800
FAx(978)745-0343
LARRY RAMDIN,RS/REHS,CHO,CP-FS LRAMDINfa'SALEM.COM
HEALTH AGENT
COMPLAINT INTAKE FORM
Date: Time: Received By:
Complaint Number: 1372
Complainant z
Address: Phone:
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Investigated By: PJ Date:
Property Owner/Occupant Name Telephone #:
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