paren of kool INTOXILYZER 5000 and Drug Yesting SUBJECT TEST FORM TES, pare ~ , | va SUBJECT NAME, Lg | a. _flennee o tomAs [patron nmi — i | jm ADDI CITY Oey Aes, ST. ; 1 = a 'sTaTe ary - I DRIVER LICENSE # ~~ Stam ” EXPIRES DEPARIMERT j| Cos aligry foe. her 1! ORDINANC ORM FRAREIC TICKET & 0-07! | ee N$23 7F WEB l| GEILJ9AIA 7 4S. en OAL | VIOLATION i TEST SEF UL, Wer zug, Seat Pax Intoxilyzer 5000 Operational Checklist Ky Observe subject for twenty minutes prior te testing t prevent oral intake of any material, Q) Press "START" button, ) Enter dala xs prompted by instrument display. () @) ‘Lake breath semple when "PLEASE BLOW" appears on display. TST RESULT | CHECK IF SUBJECT REFUSED UIST 6. BX, g/210L, PEaMITe PLUATION DATE [ ReyRCNCENY Seta STIS ie Lt | 73 | CeO yon | ae ary) ; DEPARTMENT 7 ‘bre Conan bx, Lee __|poe TP Lhd ch hpi Zit serie & eg-o19Ra4 oe HODELE SeameH suBlecr.s HANES THOWAS/THTCHAELY DAVID PERULTS EXPRESSED 98 ceaMs oF ALESHA rER 218 CETERG GF eRERTHT “QTR “EUan oe e187 BUBJEEP ect pay a8 ALR BLAM whe BEB? opeparony Kane 2 LaNTER/ TinoTHY PERATT RD ATU R470 8-9 EET soon en Coen we