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PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH <br />CHAIN OF CUSTODY RECORD <br />1. Sampler's Name lk14tle I7 �d S Depc. �✓�¢3 — &p <br />2- <br />Appendix H <br />t� a �8 -og <br />Date <br />Time <br />Item <br />Location <br />ID# <br />Unit <br />Required <br />Analysis <br />Remarks <br />Condition/Temperature <br />lv--r <br />z <br />Qhs <br />3- <br />S <br />Ic <br />3 s� <br />k-3. <br />3. Evidence tape <br />h Pigg . <br />4. Sample transported in iced cooler <br />5. Relinquished by i dj44a, <br />name title date time <br />Received by <br />name title date time <br />remarks <br />(co ndi do n/te m p era cure ) <br />6. Relinquished by <br />name title date time <br />Received b i d, �d U?1 �.�,, /0 rc�;l3 <br />name title date time <br />remarks (condition/temperature) <br />EH <br />