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Appendix H <br /> PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH <br /> ry 41itle <br /> CHAIN OF CUSTODY RECORD <br /> if1. Samplers Name �1 Dept. P -S <br /> 2. <br /> Date Time Item Location ID# Unit Required Remarks <br /> Analysis Conditionf emperature <br /> 6-3 <br /> 4-3 <br /> r <br /> W, 40NE F P; ti <br /> 3. Evidence tape [ <br /> 4. Sample transported in iced cooler �}/ <br /> S. Relinquished by — (I I f' 5 7 <br /> name title date time <br /> Received by <br /> WarnINL jP title date lime <br /> rema 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 /> i <br /> took <br />