INTOXILYZER 5000 SUBJECT TEST FORM Bureau af Aleobol and Drog Testing [vest Dare |" SUBAECT NAME, ZA L FRey E& Tbrnfsod DATE OF BIRTH BOE 2h 68 4, ‘ADDRESS ary 898% Zone At Contest ilVr? [ srare ZIP CODE. | R LICENSE # STATE, EXPIRES ow | Were RUA? OYE on | whe | | ARRESTING OFFICER DERE Shaws! _ C. werden Fo. OEP UNIFORM TRAFYIC TICKET # STATUTE ORDINANCE PE" E7b0S99 _ YSUE Ala ove omer VIOLATION = TEST SITET i Cons yy Intoxilyzer 5000 Operational Checklist {1} Observe subject for (enly minates prior to testing to prevent oral intake of any material, Q) Press "START" button. y (3) Enier data as prompted by instrument display, (4) Take breath sample when “PLEASE 13],OW" appears on display. TUST RESULT CT CHECK If SUBIRCT REFUSED TEST 0.276 _ s/0L PERMIT # EXPIRATION DATE | [ INSTRUMENT SFRIAT.# “TEST LD. (27290 -8-3 | ‘s lz ma 6-073 08) YOR7 ERATORS STPNATURE, Pos at St (Str! Wheinwion bee. flop | Cone Copp Copy: tied At fastrument Site RULFS7NAS302 MEA 2682 RE 8,200CIN 4 weak 2016} SERIAL fh eg-aiReat TODELS SeOSEH SUBJECTS NAMED JOHNOON/TROYE E Reguu7e KrRESEED AB chAME oF SLCOHGL, PER 222 LITERS OF BREATH ATE LANE: eee QUBJECT TEST aE BIR BL Ane "abe ERATOR "SHAME o LAWGCH? STEPHEN RAT PAB S