18 Porter Street 1st Floor Complaint 12-30-2015 CITY OF SALEM, MASSACHUSETTS
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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 LRAM�SALEM.COM
HEALTH AGENT
COMPLAINT INTAKE FORM
Date: ✓ Time: 06 PW Received By: [
Complaint Number: 1390
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Address: IVA 4 Phone:_-L3 3
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Investigated By: Date:
Property Owner/Occupant Name Telephone #:
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CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
KIMBERLEY DRISCOLL 120 WASHINGTON STREET,4TH FLOOR
~ MAYOR TEL.(978)741-1800
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LARKY RAMDIN,KS/REHS,CHO,CP-FS
LRAMDIN a'SALEM.COM
HEALTH AGENT
COMPLAINT INTAKE FORM
Date: % " Time: 1 f �v1 Received By: /�S ;e �,
Complaint Number: 1390
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Investigated By: Date:
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