INTOXILYZER 5000 SUBJECT TEST FORM Bureau oF Alcohol and Deus Testiag, [ TEST DATE ow ' SUBJECT NAME Le 4 | Zor's | Dor Noga Suniy ” DATEOWRINR a EY] (PB ete | 45 [ae | ADDRESS | ~ ~ cr S778 NEW BE Pasn ‘ in CCD RF). j State —~ —aypcope 1 [HRIVERLICuNSE # ~~ TxTHRLS od | gar” | 5 fasted. | BE | FEST TORIC aap _ Cash (ecpisH . em Ae Ber {FORM TRAFEIS TICKET # “S| StSTUTE) ORDaVaNcE “ DS: BUTE BA OVE ASHI? Aa . VIOLATION TEST SItE # 7 CALY L OVS leak Te Cnitned. | aed | Intoxilyzer 5000 Operational Checklist t) Observe subject for twenty minutes prior to testing to prevent oral Intake of any: material, + FJ] (@) Press "STARI™ button. Oo Enler data as prompted by instrument display. | / LH Take breath saiuple when "PLEASE BLOW" appears on display. Loy ‘TEST RESULT LU) CHECK W SUBJECT REFUSED TEST 0. fi Le g/210L PERWITE . RATION DATE INSTRUMENT SRRIAL# | | “LEST UD.# | Ayers | PVH | ae 3 ratga2) | Got. OPERATORS SIENATURE a ~ | “DEPARTMENT Fae ; aie ae Ve wan foe feAR oe a RE SIN 4 aur Ode Baie SERIAL BGG 59081 NOEL FORGEN SURPECT'S Hates amiga esuhtS 9s elena. oF ALSOHGL PER DLO LITERS DF BREATH ali, BLANK 008 SuByECT Tear REFUSED . Ale BLANK + FES OPERATOR'S NAHE, PSRHETE Cho 2 2ione. AEOARATO ANE ABABA