Evidential Breath Alcohol Testing (EBAT) Program

RECORD REQUEST

This order form is for records pertaining to any EBAT conducted using the Intoxilyzer 5000EN and performed prior to May 1, 2013,

Litigation packets for any EBAT conducted using the Intoxilyzer 9000 and performed after May 1, 2013 are now included as part of every subject test report provided by the law enforcement agency.

Requester Information

* Requester First Name

* Last Name

* Requesting Agency Name

* Street Address

Address Line 2

* City

* State

* Zip Code

* Phone Number

* Fax Number

* Email Address

Confirm Email to receive a copy of the record request

Record Information

* Defendant Name

* Case Number

* Date of Offense

* Intoxilyzer Serial Number: 68-

* Law enforcement agency where Intoxilyzer
instrument is located.

* Standard Solution Lot Number

Enter lot number above as: # - ## - ##

Records Requested

* Send the following record(s):

*Litigation packet (includes intoxilyzer certificate, certification record, service history and unsigned copy of standard solution label.)

**COBRA records

*If a signed copy of the solution label is needed, contact the law
enforcement agency where the Intoxilyzer instrument is located directly.

**COBRA records - 30 days before and 30 days after date of offense
will be provided, unless indicated in additional instructions box.

Additional instructions:

All records are deemed certified by the
Colorado Department of Public Health and Environment.

A certifying statement signed by the Laboratory Services
Division Director will accompany each request.

Billing

All records printed will be sent via United States Postal Service.

Litigation packets = $5.00
COBRA records & any other items = $0.25 per image

Invoices will be mailed monthly.

For assistance please contact the EBAT Program at
303-692-3295 (voice)
303-344-9965 (fax)

* Indicates Response Required