11 Summit Ave Complaint 12-1-2018 CITY OF S.ALEM, MASSACHUSETTS
BOARD OF HEALTH
KIMBERLEY DRISCOLL 120 WASHINGTON STREET,4r"FLOOR
MAYOR 0 FAx(978)745-0343
LARRY RAMDLY,RS/REHS,CHO,CP-FS LRAMDINih?SALEM.COM
HEALTH AGENT
COMPLAINT INTAKE FORM
Date: l Time: Received By: f
Complaint Number:
Complainant C
Address: i µl C��r1,,; 7��� �_ Phone:
12
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Investigated.By: Date: _
Property Owner/Occupant Name_ __ Telephone#: