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1. Sampler's Na <br />�/Jm <br />� e <br />2. ( ),A 9_ <br />PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH <br />CHAIN OF CUSTODY RECORD <br />Title Dept. <br />')(,r ,, _ I - C_ I- r? '-) � r, , 1 <br />Appendix H <br />Date <br />Time <br />Item <br />Location <br />ID# <br />Unit <br />�3p,� <br />Required <br />Analysis <br />Remarks <br />Conditionfremperature <br />l xu! <br />?� <br />l <br />u -_')-P-) <br />P�V -, <br />C Q. <br />QS_ 1V4tf__ <br />3. Evidence tape i <br />4. Sample transported in iced cooler [] <br />S. Relinquished by ------------ <br />name title date time / <br />Received by 10�0V\ :� <br />name title date time <br />remarks (condition/temperature) <br />6. Relinquished by <br />name title date time <br />Received by 1�� - Z�b <br />namd title .eL date time <br />EH _- — 13 <br />7 3 5Y:) <br />N ao1-5zq <br />,�aot3Z5 <br />dao � 3 2 6 <br />Sao t <br />3Z-7 <br />Nadi 3z-9 <br />