NTOXILYZER 5000 SUBJECT TEST FORM Bureau nf Alcodel and Drug Teating [ Test DATE SUBJECT NAME, o5 | & Bay Aegare DATE OF BIRTH AGE, 1 [sf SEX ed ot ADDR! cary Mata Locen ewan, Cue. | Love wags . FIP CONE DRIVER LICENSE # STATE ‘EXPIRES | #540 RYINSISZ ou efor. TRRERTING OFFICER DEER ATENT ~ Behe forse Coreen Lorie TNFR TRAFFIC TICRETF | BAT Fo ORDINANCE TS" 3pyey 94 ie soe TOT ATION SOS Lin # dntoxilyzer 5000 Operational Checklist * TEST SIE # (1) Observe subject for twenty minutes prior to testing tu prevent oral intake of any kal material. ir (2) Press "START" button, () Enter dats as prompted by instrument display. | (4) Take breuth sample when "PLEASE BLOW" appeary on display, TEST RESULT Ly CHECK A SUBJECT REFUSED ‘TLS 0, ar? 6 210L EXPIRATION DATE, “| [INSTRUMENT SERIAL # "| FEST ED.# vo |as | je O5-O0GOB) ob TERMITE Jo-484- $3 | ue OFRTATORY BIGWAJURE DEPARTMENT rte) &. éy, ieewrominas DCejede Original: Court Cony Capys Pg asp 6 AL pSirument Site RULE. 3701-51-02 HEA 2652 RRV 8:2007Nas doraertote ope or Roper’ Sonaek af, 68-8 ia0 — “8 HANES ABBOTT/BRYCE/E, SSED. AG GRAMS OF 216 LTTERS OF. BRERTH All BLENE RUDECT TESse AT BLAS OPERATOR'S MANE = ROETTENG/HICHAEL FERRITE PeAssn3 “Bryer RP Aggarr Agasre. 18S 0 Geemarc