TOXILYZER 5000 SUBJECT TEST FORM Bureau of Alcohol sand Drug Testing EST DATE ] | SURIFCT NAME ol 2B Lt bh Whee Dame OF aneTA AGE TEx a3 | op | ge 2s. Las ||_m Le | ADDRES Ave cITy _ FE STATE. ZIP CODE ] | DRIVER LICENSE # ~ STATE EXPIRES oH__| ystab LS 2bis Lew | aZasy_| ‘SRRERTING GPRICER DaPARTMENT Mots " Cate. £D DEY | UNIFORM TRAPTIC TICKET # STATUTE / ORDINANCE Be BIS ORE . H5trabe — OVE SYS. Mala VIOLATION ” ~ Pasi uke ie Conroe. | Intoxilyzer 5000 Operational Checklist TEST SEF CIN 4 (1) Ohserve subject for twenty minutes prior to Lesting to prevent oral intake of any material, (2) Press "START" button, {Q-Foter data as prompéed by instrument disptay. (4) Take breath sample when “PLEASE BLOW” appears on display. THST RESULT CULCK IF SUBIRCY REFUSED TEST 0257 gi210L B476(-5-3_|| “eb | Hi leove ‘OPLRATORS SIGNATURE ” DePARTMENT DLO b.Poenlo- | Lcowrr. £0. / pst 4 Originals Cour: Copy — Copy: Filed At hasaruanens Site RULE 3791802 IKA 2682 REV 82002 PRRMIT & - PXPIRATION DATE . | INSTRUMENT SERIAL # | TEST LD.# &8- 01303) | peaf : hon {err Oe cin 4 es tay anne RIA, “H Se~B1S0R8 MOORL eB@cH SOLO INJECT'S HANEY REMLLLTHPERTOAL FEGULTS EUPRESOED pg GRANE OF. ALEOMGL PER cle LITERS OF eRenth ATR ELAN 1808 BEA SECT TEST aBt Bane. ATR BEANE MABE kd OPERATOR'S MAME =! PLoS? roDD PERTETR aera l--3 Tea HE bpp