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Appendix H <br /> PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH ^ r <br /> DD <br /> CHAIN OF CUSTODY RECORD <br /> Dept. <br /> 1. Sam ler's Name <br /> S - <br /> p �S� L, Title S t=_ H S _� H � <br /> 2- <br /> Date <br /> Date Time Item Location ID# Unit Required Remarks <br /> 4.mr Analysis Condition/Temperature <br /> y,2 9Fa — `7 f3. Evidence Evidence tape <br /> 4. Sample transportedd i/n�-iced <br /> _ co/oler <br /> S. Relinquished by <br /> name title date time <br /> r <br /> Received by <br /> me title date time <br /> remarks ('condition/temperature) <br /> 6. Relinquished by <br /> name title date time <br /> Received by <br /> name title date time <br /> remarks (condition/temperature) <br /> C <br /> EH___ I 13 <br />