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INTOXILYZER 5000 SUBJECT TEST FORM Bureau of Alcelol and Drvg Testing [TEST DATE — "Ge | RS | Bio SURIECT NAME “Tae “TEREELL AGE SEX We | _ xj LETe | [svoRESS jgauf MEROMAO ar CHT, eee fo ee ve | Lib Cide prZ. J STATE ~ FIP CODE DRIVER LICENSE ~ . SLATE EXPIRES: ot | Fezel BU LOB U0s 6H | Rb2 a Cal BEchke | UNIORM TRAFFIC TICKET # DE- BLUCYRO Ove [orragrvanr Cal; LTT foc ber STATUTE ORDINANCE OVES. BiG VIOLATION = sfhepnie Intoxilyzer 5060 Operational Checklist Al) Observe subject for twenty minutes prior to testing to prevent oral intake of any material, [“] (2) Press "START" button. HG (3) Enter data as prompted by instrument display. oY (a Talce breath sample when "PLEASE BLOW" appears on display. TERT RASULT a g/21 01 INSTRUMENT SURIA Cue CK.LF SUBIECT REFUSED TEST PREMIT F ASETSS FAPIRATION DATE e YaspRb.# IF | 8 | 20m - OF 6180} al CUERATORSBAA C Oy Lol | oe ~ Crean Pu

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