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i <br /> Appendix H <br /> PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH <br /> CHAIN OF CUSTODY RECORD <br /> 1. Sampler's Name go _, Title S F. H S Dept. <br /> Date Time Item Location ID# Unit Required Remarks <br /> 1T Analyss Condition/Iemperature <br /> y.t 99a - 7 <br /> 77 <br /> 4aw <br /> 3. Evidence tape pt j -rAc t w J uy o <br /> ww[ <br /> 4. Sample transported in iced cooler E. Varoma.. <br /> S. Relinquished by,I,Z4,- , fI S Y-A . <br /> name title date Lime <br /> Received by& 7"vs% <br /> me title date <br /> time <br /> remarks (condition/temperature) <br /> 6. Relinquished by �� _ /qt�� S SQL 57Z /G : L{ / w <br /> name title date <br /> time <br /> Received by <br /> name title <br /> dace time <br /> remarks (condition/temperature) <br /> e Ls <br /> EH__ / 13 <br />