INTOXILYZER 5000 SUBJECT TEST FORM Bureat of Alcohol and Drug Testing TEST DATE SUBIECT NAME 0. ] Bran NN Boukias ADOTESS - —T 210 Glenwood fv ; . Ciné snag te STAT zis cont [amv TICERSE “STR ENTIRE I I 6 | Yea2q |L_ Wone/parnnar! af | 1603 ARRISTIVG OFAC ° | DEFATTMENT 20. Corbess Cineinnati “9, UNUORM TRAFIC TICKET # \| STATUTETORDINANCE YB). 7G, 7S 3731697 iY SPA, GEL TISLanON Tas SF UL, Sia Sinn , WOE. Lieias Intoxilyzer 5000 Operational Checklist | (£) Observe subject for twenty minutes prior to testing to prevent oral intake af any material. (2) Press "STAR" button, bX] (3) Enter data as prompted by instrument display. (4) Take breath sample when “PLEASE BLOW" appears on display. TEST RFSCLT CIULECK I? SUBJECT REF ‘west 0. {Gt _ 9/210L 7 L/S | Yo || G8 013931 OPERATORS SI@hATURE | DEPARTMENT Originals Court Copy Copy: Piled 40 hastrument Site RULE 3101-83-02 HEA2S REV 42602 Pra ~ 7] [esnaitiowpari’ | [RSTROWENT SRT e I TST: GBH | 5-5 Gin blCEP Te Re ee age AUT IaRpeOA £8 meas ‘ cae at as Ba/ 2080 SERIAL, 4 Ga—e19091 HODELE, Saute SUITECT‘S NOME? BOYRINGY ERANOTSN FEU RANG OF AC ORAL oF BREATH bas Bs Preis 643 38° QERRATOR SHANE NcooHgUBH/ HEBERT SERRE elaine each gt —$§> 7 A es AA Sees