Bureau uf Alechol und Deug Testing VST DATE L5\dA INTOXILYZER 5000 SUBJECT TEST FORM TSUBIECT NAME. hfe stoptif. © Pleat DATE OF BERTH 3_ 1 a9 1979 AGE | mM [ADDRESS oe | Ysorg STING OFFICER ~ B “Bias UNIFORM TRATBIC TICKET & Tl crpy | ovcrumans "DRIVER LICENSE? || zg ace IL STATE au | DEPARTMENT a a STATUTE; ORDISANCR 75 -3756EA7 YUM A VIOLATION Ob +b | Intoxilyzer 5000 Operational Checklist i] (£) Observe subject for twenty minutes prior €o testing to prevent oral intake of any material. (A) (2) Press "START" button, 4 (3) Rnier data as prompued by insteument display. (4) Take breath sample when "PLEASE BLOW" appcurs on display, TEST REST 0, WY g/10L CHECK EF SUBIECT REFUSED TEST PERMIT? FATIRACION DATE £0 |23 INSTRUMENT SEREAT B8ese%2 TEST EDF Leese _ (2 Fo: 154 $3 vent REV 82002aus 8/22/2880 SERIAL 4 69-0x61 HODEL® Beceen SUBIECTS MPM BLaIR CRM Larrabee 2g Ts PRESSED ne ckMNS_ OF ACEOHBL PER 210 LITERS GF BREATH SER BLANK 60 aa S3 Suutecy Tes’ 1418 OBE Ee BLANK Laue 931t8 APERGTOR'S MANE = ROETTINA/ ICHAEL PERAITE PEG 6-3 B.