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Appendix H <br />PUBLIC HEALTH SERVTCES <br />ENVIRONMENTAL HEALTH <br />CHAIN OF CUSTODY RECORD <br />1. Sampler's Name (so 'Title Suocru—s- Sor Dept. ?Hs- f/41) <br />2 <br />Date <br />Tune <br />ltem <br />Location <br />,U.Ct l'FS <br />1D* <br />Unit <br />Required <br />Analysis <br />Remarks <br />Conditiott�Iemperature <br />� <br />a 4S <br />9:� <br />y <br />A -1 <br />940AS <br />q'.45 <br />IZI <br />i I <br />I <br />I <br />i <br />I <br />� <br />I <br />i <br />I <br />3. Evidence tape <br />S. Sample transported in iced cooler <br />j%- N° /v /,",/,ax, <br />6. Relinquished by cJ�Le-u Z// <br />name title date time <br />Received by �1 _ �-'SS gq-20-ci5-, ' <br />am title date Lime <br />6. Relinquished by <br />remarks (condition/temperature) <br />name title date time <br />Received by <br />name title date Lime <br />remarks (condition/temperature) <br />EH__ 13 <br />