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Appendix H <br /> PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH <br /> CHAIN OF CUSTODY RECORD <br /> y�h��ags/�V1 <br /> 1. Sampler's Name Title SMIY'MldV1W{,IM1 Dep[.�1Ll�of[l+►+tri <br /> 2 <br /> Date Time Item Location ID# Unit Required Remarks <br /> Analysis Condition/Temperature <br /> �1 til•tib 1,�M X41 s5 �n � S� ltsh rt Gntm M M G <br /> c�a t 5T - S&1. # <br /> =CLU G Lp C Csn <br /> � � Go w�,5a✓1 . <br /> Zai �1- �xtiQ � <br /> 3. Evidence tape <br /> 4. Sample transported in iced cooler t <br /> �,,� <br /> 5. Relinquished by �y�hy�y1Y4�L11-•14A ': <br /> name title dale time <br /> i <br /> Received by ,, <br /> name title date `tim <br /> remarks (condition/temperature) <br /> b. Relinquished by <br /> name title date time <br /> Received by <br /> name title date time <br /> remarks (condition/temperature) <br /> i <br /> • J <br /> EH--- 13 <br />