20 Harbor Street Complaint 4-27-2016 a
CITY OF SALEM,MASSACHUSETTS
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 LRAMDIN(a'SALEM.CGM
HEALTH AGENT
COMPLAINT INTAKE FORM
Date: Time: �. /! _ Received By: ox
Complaint Number: 1502 /
Complainant Ot 6
Address: Phone:
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Investigated By: Date:
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CITY OF SALEM MASSACHUSETTS
BOARD OF HEALTH
KIMBERLEY DRISCOLI. 120 WASHINGTON STREET,4TH FLOOR
MAYOR TEL.(978)741-1800
FAx(978)745-0343
LARRY RAMDIN,RS/REHS,CHO,CP-FS I.RAMD1N61J SAI.EM.COM
HEALTH AGENT
COMPLAINT INTAKE FORM
Date: Time: M Received By:
Complaint Number: 1502
Complainant ✓ ;', ` 4i.r
Address: ` ( r .it �; ��- ,� Phone:
Investigated By: Date: _
Property Owner/Occupant Name Telephone#: