4-6 Hazel Street Complaint 8-19-2019 �onwr
` .. h CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
KIAIBERLEY DRISCOLL vat 120 WASHINGTON STREET,41H FLOOR
MAYOR TEL.(978)741-1800
FAx(978)745-0343
LARRY RAMDIN,RS/REHS,CHO,CP-FS LRAMDLN@SALEM.COM
HEALTH AGENT
COMPLAINT INTAKE FORM
Date: � �� Time: ,�, Received By.
Complaint Number: 2540
Complainant &m~01.5
Address: —^ Phone:—
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Investigated By: Date:
Property Owner/'Occupant Name_ __Telephone #: