NTOXILYZER 5000
SUBJECT TEST FORM
Bureau af Aleahol
and Drog Testing
TEST DATE SUBJECT NAME,
OS oF Shane ChANGy
DATE OF BIRTH
ae | ia
ADDRESS: ~ . CITY
Oe BLOTTER, AVE CRANMATY
STATE ZIPCODE DRIVER LICENSE # STATE “EXPIRES
o Ysars | RI 2ZOOVT ou | 3fu
ARRESTING OFFICER [DEPARTMENT
Po Boer wt | ceo ber 4
UNIVORM TRAFHIC TICKET # ] STAIUIE ORDINANCE,
75°32 SER ASM HM .
[ VIOLATION TES! SITE
OO -Gl Cul
Intoxilyzer 5000 Operational Checklist
(1) Observe subject for twenty minutes prior to testing 4 prevent oral Intake of any
material.
Q) Press "START" buttan.
(3) Enter data as prompted hy instrument display.
(4) Take breath sample when “PLEASE BLOW" appears on display.
TEST RESULT
CHECK IF SUBICT REFUSED LEST’ 0,464 g/210L
PFRMITH EXPIRATION DATE INSTRUMENT SERLALY | [ TRSTLD#
76.484 $3 | (o_|az | te OB O/503/ GO Sk
OPERATORS TUN ATURE [aeaitineNT
Cninna uce |
RULRSTI-S-02 —-HEA26E2 REV 8/2002 cha
esfarszaia SERUNG # gacpscont
ODER booeek
SUBTECTS NAMES CHANETS MEREDITHES
RESULTS EXPRESSED Aa GRNNS OF
ALSONGL Pee BIO TC ITHes UF BREATH
ARR Bhar P08” az202
SbavEte Fear lied = Gea
AER BLANK 1668 O2red
OPERATOR'S NANE« ROETTINGe MICHAEL,
PERATTS ‘TedBe
EASES
ore
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