TOXILYZER 5000 SUBJECT TEST FORM Bureau of Ateaho) and Drug Vesting TEST DATE ~ SUBJECT NAME | a5_| 22. Ah (CHOLAS Linen LVM ETT DATE OF BIRTH AGE | | SEX ”Y wa FF lo | a"! ie ee ma | ZIP CODE. | [ DRIVERTICESSEF STATE, SBE LOSYEED Be 2, ARRESTING OFFICER ~ DEPARTMENT He. Porat. Eo ateioln TRTFORW TiLAPC TIOET | STATUTE? ORDINANCE 23 - 2786 §20 x VIOLATION 7 [Stor iE SLIM OC | Loud Intoxilyzer 3000 Operational Checklist ] (1) Observe subject fv twenty minutes prior to testing tu prevent oral intake af any material. EI (2) Press "START" button, (3) Enter daca as prompted hy instrument display. [X} (4) Take breath sample when "PIEASHE BLOW" appears on display. TEST RESULT [~] CRECK Ly SUBJECT REFUSED TEST 0. LED g/2 101. PERMIT? PXPIRATION UATE | INSTRUMENT SERIAL TEST LD. Lbs 53 | 20b, LEWDES | YIED OPERATORS SIGNATURE. 7 DEFARYMENT ~ 2 Bey ORB, up| Evin Biux Original: Court Copy Cul FiledAT Instonmern Site RULE 3701-83.02 MEA 2652 REN 8.2002i aA Sm ‘QUTH Kuo RIOR ha apr ci OE CRM 6 ery wae 7018 FERIA § eaediaseru, ROEELA Seong SUBIECT'S MANE: DURRETT/NICHOLASZL RESULTS EMPRESCEY ag erate’ OF ALOOHOL PER 218 LI TEs Oh BREATH AR BLOM ORD agi ge. Sigseer esr. Tiah 83280 ARE BLANK rebe = 0a: QPERNTOR'S MANE» PORTTINOSMIEAEL PERMITE PeAhd-S-3