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appendix H <br /> PUBLIC HEALTri SERVICS <br /> ENVIRON4tENTAL H2.ALTI-I <br /> CHAINOFCUSTODY RECORD <br /> I. Samptc:s Nam9I� � 61 lvL S Dept �G kj� <br /> � <br /> d <br /> Date T-Lme Item Loadan I M# Unit Required Remarks <br /> Anatysis Condition/Teraperaturc <br /> tS � . i Bio <br /> JOS 12 s I 3 �., � so��,; Sew C�o(a.� 2� �W : <br /> be <br /> I I � <br /> I <br /> 1 I I I I <br /> 3. Evidence tap6- <br /> 4. Sampte transported in iced cooter / <br /> 5. Relinquished by <br /> name tide dal time <br /> Received by C �GJ G 02 ?Cc,S S <br /> name tide date time ` 3 <br /> rctttarks (coadidoaltempertture) <br /> 6. RetinquCshed by J <br /> name dt date time <br /> Received b <br /> �f 1/SCJ <br /> me ddedate —� udte <br /> ttremarks (coadidoaltemperature) <br /> A le\,QA ktLZ irrcti�e QtoaSS�7 ' 1 k <br /> �zr �rk4,c, ( („«1�- N^-�L..-Wc Le— 4 l-fur JY <br /> � <br /> k-� 2 Gk"'S0 / <br /> EH T; <br /> l <br />