5 Station Road Complaint 5-17-2019 ntiUitq'.. �4:��(.ems �• �/
CITY OF SALEM, MASSACHUSETTS
Y 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 LRAMQUj SALEM.COM
HEALTH AGENT
COMPLAINT INTAKE FORM YAD Time: ,t y, Received By:
Complaint Number: 2446
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Complainant
Address: —57] J fi 5 Phone:
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Investigated By: Date:
Property Owner/Occupant Name Telephone#: `