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0 CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
KIMBERLEY DRISCOLL 120 WASHINGTOh'STREET,4T"FLOOR
MAYOR TEL.(978)741-1800
FAx(978)745-0343
LARRY RAMDIN,RS/REHS,CHO,CP-FS LRAMDIN(U SALEM.COM_
HEALTH AGENT
COMPLAINT INTAKE FORM
Date: Time: Received By:
Complaint Number: 0548 I
Complainant_e
Address: Phone:
7-1
aA
Investigated By: G►C%R,4 at�AV+" Date:
Property Owner/Occupant Name Telephone#:
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