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Appendix H <br /> PUBLIC HEALTH SERVICES <br /> — �- ENVIRONMENTAL HEALTH <br /> CHAIN OF CUSTODY RECORD <br /> g � ` <br /> 1. Sampler's Name1 � G5i`Title Dept. P S <br /> 2. i <br /> Date Time Item Location ID# Unit Required Remarks <br /> Analysis Conditionlremperature <br /> 5-3 <br /> Stu�; t <br /> �1 � �� fu R' 1`- <br /> i <br /> I <br /> I <br /> i <br /> 3. Evidence tape n <br /> 4. Sample transported in iced cooler <br /> S. Relinquished by r) S 5— 3" (l f S <br /> name title date time <br /> Received by G a.� (S--.5 `,. /• <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 /> O� K <br /> S <br /> EH <br />