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About You
Breath Alcohol Test Record
Test Results


BrAC ug/100ml


Blank 1

Simulator Check 1

Blank 2

Breath Specimen 1

Blank 3

Breath Specimen 2

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Simulator Check 2


I certify that in this statement, reading one relates to the first specimen of breath provided by the subject named above and reading two to the second, at the date and time shown herein.