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Appendix H <br /> PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH <br /> CHAIN OF CUSTODY RECORD <br /> L . <br /> 1. Sampler's Name Y , Title Re Dept. <br /> 2. <br /> Date Time Item Location ID# Unit Required Remarks <br /> Analysis Condition/temperature <br /> S Ixh%VOV Fw✓*.. 2 11 220 ui <br /> 11,1i�N+�YYWP d1t <br /> rim <br /> ;�2s 4 II w .1a594ur1:DM <br /> %cu- Co�n <br /> 3125 f I �G rbD Ck"f5 ?�cll4LAID 3R <br /> � C4a,�btt s,tv �S <br /> C a4 'L✓^' <br /> I��y l ;S0 asK dM� 2 71;' tfLAp4A <br /> rrrpw� <br /> Ij5 y l(:53 vl�le wum <br /> Lu G1,16 <br /> 3. Evidence tape [] <br /> 4. Sample transported in iced cooler [] <br /> 5. Relinquished by , <br /> name title date time <br /> Received by <br /> name 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 /> EH __ 13 <br />