NTOXILYZER 5000 SURJECT TEST FORM Bureau of Aleahel and Drug Testing [TEST Dare SURJECT NAME osm) may 5! lo Dames eo Aa ge DATE OF BIRTH ox ar [ ADDRESS | Pen | Catenin art STaTe LAVIN of RI Bw Boon ot | 1996 [Aigtes TING OFFICER DEVARTWENT ~~ Cyt Buetwen ober Shas CRMORM TRATHO TICKET # [TUTE] ORDINANCE 13° G1 aay ss J__ owe f $sit19 ala VIOLATION | TES ee Féhuwe Po CyuF po : Gat Intoxilyzer 5000 Operational Checklist |_{) Observe subject for twenty minutes prior to testing to prevent oral intake of any material. ~ (2) Press "START" button, (3) Enter dats as prompted by instrument display. (4) Take breath sample when “PIEASE BLOW" appears on display. TEST RESULT 4 CHECK I SUBJECT REFUSED TEST 0.2 to 2/210L PERMIT # “EXPIRATION DATE, INSTRUMENT SERIAL TESTED. # ev | oer rae (of 82! Goer. . [DEPARTMENT 2 Crnstri art hee Orighaly Com Copy — Copy: Mtoe Ar Incirumen Site RULE 3701-53-02 HEA 2652 REV 8/2002CIN ¢ eer as 2058 SERIAL # BB-C1aeE4 HOneLs Seeeets CUBIECT'S NAMES HILL/TANESH PEGULTS EXPRESSED 8S, BRAN. OF ALCOWG, PER 24s TLveRe CF OREATH Ae BLARI A Bh Ba SQBTEGT Teer. 4G Gta Fue SLANE roa B11 3L QRERATOR'S HAME, =. BLACKWELL! CARL: PERALTE Bog