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Name _.L [ Address
Owner Tel. No.
Type of Inspection Inspector
( � ) Remarks and Violations are listed below:
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Report Received by: �_
Inspection of Date . Time
Name Address
Owner Tel. No.
Type of Inspection Inspector
( * 1 Remarks and Violations are listed below:
Report Received by:
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r CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
KIMBERLEY DRISCOLL 120 WASHINGTON STREET,4r"FLOOR
MAYOR TEL.(978)741-1800
FAx(978)745-0343
LARRY RAMDIN,RS/REHS,CHO,CP-FS LRAMDIN .SALEM.COM
HEALTH AGENT
COMPLAINT INTAKE FORM 1
Date: Time: Received By: � _
Complaint Number: 1921
Complainant k"
Address: 1 �/�I.� ✓��� Phone:
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Investigated By:��r Date:
Property Owner/Occupant Name Telephone #: