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Appendix H <br /> PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH C:(DP)7 <br /> CHAIN OF CUSTODY RECORD <br /> 1. Sampler's Name Cc Title S RE H C Dept. 5— E74 n <br /> 2. <br /> Date Time Item Location ID# Unit Required Remarks <br /> Analysis ConditiorvTemperature <br /> -A� ��t.r 1Y)eT &u, rS) r co m ��y-/0 - <br /> f( /-.- a y <br /> T-Y.d YJ h RIO sCN�A>s <br /> c 1 <br /> ' n L <br /> /•Z�/�' � ti( /� % � �� ��D�'7 L is � Il <br /> J� <br /> 3. Evidence tape <br /> 4. Sample transported in iced cooler <br /> 6. Relinquished by, h'0 %� , S F h 141� <br /> name title date, time <br /> Received by,:� , �/ /�j� �7��.7. <br /> name title date time <br /> remarks (condition/temperature) <br /> 6. Relinquished by �-�T % S�Z f Q : e S�� <br /> Erne title date time <br /> Received by- <br /> name title date time <br /> remarks (condition/temperature) <br /> I �-�s �,�of r� �, � Iqs <br /> EH __ 13 <br />