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t Appendix H <br /> PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH <br /> i <br /> / p CHAIN OF CUSTODY RECORD <br /> 1. Sampler's Name �r-S4&sck Titie R S Dept. FPS — E. , <br /> 2- <br /> Date <br /> Date Time Item Location ID# Unit Required Remarks <br /> Analysis Condition/Temperature <br /> JO 7- <br /> 'N r rr Shu rv+ <br /> �i�b.'1t.t CLtN 'f Z i I'LC� <br /> I <br /> 3. Evidence tape <br /> 4. Sample transported in iced cooler <br /> 5. Relinquished b aSC.rli R NS <br /> name title date time <br /> Received b - :15 <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 />