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Appendix H <br />PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH <br />CHAIN OF CUSTODY RECORD <br />1. Sampler's Namet Cktle Isld� DepL /PG,s —�-, <br />2. <br />Dace <br />Time <br />Item <br />Location <br />ID# <br />Unit <br />Required <br />Analysis <br />Remarks <br />Condicion/I'emperature <br />/0 <br />LIJ <br />/v --f <br />5 Z <br />�, <br />Qb <br />t o-' -`15 <br />5-- <br />< <br />tis <br />- <br />7,417 <br />/0.--C/5sh, <br />3. Evidence tape <br />4. Sample transported in iced cooler 0 'T-cr ,� �r SCAV-Vple-g . <br />S. Relinquished by -7/i Gfcj !f eEr' S lc,11,15� 7, /g' •` -r <br />name title date time <br />Received <br />name title date time <br />14 <br />remarks (condition/temperature) <br />6. Relinquished by �� �"~"� 4E� io1�S�Sg /('•' <br />name title date time <br />Received by� <br />name title date time <br />remarks (condition/temperature) <br />EH 13 <br />