INTOXILYZER 5000 Furean of Aleobol and Drug Testing SUBJECT YEST FORM THST DATE SUBJECT NAME DATEGE BIRTH a @ ADDRESS S77 Compton Ave. Cineinn ake’ STATE, ZIP CODE | OK | YFa3t DRIVER LICENSE # SS G94 379 STATE ARRESTING OFFICER An Willer — DEFARTMENT Cin tinned: PL). UNIFORM TRATEAC TICKET # 75> 373 30n STATUTE | ORDINANCE VIOLATION TST SITEe Cis Intoxilyzer 5900 Operational Checklist Xl wonterial. & 2) Pre "START" bution. (4) Tule brouth sample when "PLEASE BLO’ xX CLIECK LF SUBJECT REFUSED TEST (1) Observe subject for twenty minutes prior to testing to prevent oral intake of any Xl (3) Roter data as prompted by instrument display. appears on display. TRST RESULT 0. g20L PERMIT | S/84I-S° 3 g EXPIRATION DATE TEST LD. Cn ‘S| oO | oe RUMENT SERIAL. # C&-0130>4 (ATURE Original: Cours Cony Copy: Pied At tostenmment Site | [ DEPARTMENT Oa a nate 20 RULE S7)-53-02 HRA 2652 REV 8/2002CIN 4 9842472018 SERIAL § eB-DITOSL , MapaLa SeecEn vy NOHEY RALING/ DRUADIP sun PESULTS EXPRESSED AS (ORAS CF RSG Ea Sie Ease eer AiR gLune geo, adhd Sibseer rest eeUeeD Our Ae SIR BLAM roee Blase cOTER'S NRE = cbprp seu ROwE 1TH ai sdi Ee a 7 — chad Me Splles peg —— © sR TOU Ch