TOXILYZER 5000 SUBJECT TEST KORM Borvas of Aleobal and Drug Testing [musipare en | SmTRET Naa pe | 2) | vo Bere eal b~ DATROF ART, i Rae aux lett | eats Las |_| oF DRIVER LICERST on | eaea06 | y Sit Fe 574 TSRRESTING OvTeER “—) FpERSRIMINT Pb. 2) Gawss prsy | Crating for Ber UNIFORM PRAFELC TICKET # ~ LS" 27S 208y | STATUTE] ORDINANCE TRE ‘VIOLATION —~ TES | Sony I ove Intoxilyzer 5600 Operational Checklist i Hiv Observe subject for twenty minates prior to testing to prevent oral intaxe of any material. g wo Prese "START" button. Ma) Unter data as prompted by instrument display. Lj 4) ‘Vake breath sampie when "PLEASE BLOW" appears on dispis; TES? RESULT ae CUECK TP SUBIFCT REFUSED TEST Oe. /35 gf OL, PERMIT # EXPIRATION DATE INSTRUMENT SERIAL & TEST LD. # - log ere |. 68> or303/ || aw ¥ OPERATORS APNALURE foe \Chimnnn te Dip' Oe RRND SERIA 4 sano isa! PODELIE S06GEW SURIECT*S NAMES RIMGCEREC/T RESULTS ENPRESBED AS GaAs OF ALEOHGL PER BIG CUTERS BF BREATH ff Lens oh ORE: SUITERT Mis ace AIR BLAH CL GPERNTOR'S NAME © HACHENHE THER! ICH PERNITS Peedi