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Aooendix K <br />PUBLIC HEALT-ri SERv10ES <br />aNVIRO NMENTAL. FM LTIH <br />CHAIN OF CUSTODY RECORD <br />1. Sample"s Name 1 'Ze. Title �?� Dept_ (P <br />2 <br />Date T"►me Item Location ID Unit Requires! Remarks .I <br />Analysis Condttton(I'emp� t C L 3 <br />r ehrz- � ca,,.,, <br />Zqd Lg IZ1 j� <br />'' <br />c <br />3. Evident: tape t' L <br />4. Sample =rzsported in iced cooler LT <br />5. Relinquished by (L� 5 <br />i 17LE <br />title <br />date <br />ume <br />Ad fnc!� <br />S'r7—o� <br />3�S SS <br />Received by <br />as title <br />date <br />time <br />V A- <br />rks (conditionitemp4raLure) <br />r <br />r—I r'=L <br />7)UN_ <br />a Relinquished by <br />title <br />time <br />date <br />name <br />CA, <br />Received by <br />tit <br />date <br />time 9 <br />nle <br />ame <br />remarks (ca nditionitemperaLure) <br />