MISSOURI DEPARTMENT OF HEALTH AND SENIOR...
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MISSOURI DEPARTMENT OF HEALTH AND SENIOR SERVICES STATE PUBLIC HEALTH LABORATORY BREATH ALCOHOL PROGRAM INTOX EC/IR II MAINTENANCE REPORT REPORT #3 Complete this report at the time of the regular monthly preventive maintenance check (not to exceed 35 days). Complete this report whenever the instrument is serviced or repaired and whenever it is placed into service. Retain the original and send a copy within 15 days to the Breath Alcohol Program, DHSS. INTOX EC/IR II SN 12680 NAME OF AGENCY SLMPD BAT VAN DATE OF INSPECTION 04/03/2017 LOCATION OF INSTRUMENT (STREET AND CITY) 2150 S 59th St ST LOUIS TIME OF INSPECTION 14:23 CDT CHECKLIST: Place a mark in the box by each item if found to be satisfactory or is operating within established limits. (Write in observed values where determined) . Unmarked items must be corrected before using instrument. DIAGNOSTIC RECORD ' BLANK CHECK EICO2 CHECK ta FC 1 TEMP 'MELON CHECK OSRC TEMP EFCB CHECK raDET TEMP ta RC COMP CHECK EIBT TEMP ta CRC CAL CHECK EISTD 2 TEMP ETRINT TEST 'METH CHECK BREATH ANALYZER ACCURACY STANDARDS OSIMULATOR SOLUTION EICOMPRESSED ETHANOL-GAS MIXTURE IMSTANDARD SUPPLIER INTOXIMETERS LOT# AG531302 EXP. DATE 11/09/2017 SIMULATOR TEMP (34°C +0.2°C) SIMULATOR S/N SIMULATOR EXP DATE OCALIBRATION Run and used. CHECK - (ONLY ONE STANDARD IS TO BE USED PER MAINTENANCE REPORT) three tests using a standard solution. All three tests must be within +5% of the standard value must have a spread of .005 or less. Mark the box corresponding to the standard solution being (PRINTOUT ATTACHED) 0.10% STANDARD - MUST READ BETWEEN 0.095% AND 0.105% INCLUSIVE 0.08% STANDARD - MUST READ BETWEEN 0.076% AND 0.084% INCLUSIVE 0.04% STANDARD - MUST READ BETWEEN 0.038% AND 0.042% INCLUSIVE TEST 1 - 0.079 g/2101, TEST 2 ,'.' 0.079 g/210L TEST 3 — 0.078 g/210L INDICATE THE NUMBER OF BREATH TESTS /N THE FOLLOWING RANGES SINCE THE LAST MAINTENANCE REPORT: REFUSALS 0 0-.04 0 T .05-.09 0 .10-.14 0 .15-.19 0 OVER .19 0 =ST AN( NEW PARTS AND DBSCRIBEMY — AUTEMTION OR MODIFICATIO1T SATISFACTORILY AND WITHIN ESTABLISHED LIMITS (USA OTHER SIDE INSPECTING OFFICER • .. THAT — WAS MADE TO khSTORE THE INMITRIEN' TO OPERATE IF NECESSARY). CHRISTIAN, SCOTT T . y 6 4 I? MB 250291 EXPIRA1ION DATE 12/02/2017 •ihbhPHOME NUMB ER (314 ) 444-5345 RETURN COMPLETED REPORT TO THE: Breath Alcohol Program, Missouri Department of Health and Senior Services, Southeast District Office, 2875 James Blvd, Poplar Bluff, MO 63901 MO 580-2899 AN EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER services provided on a nondiscriminatory basis LAB 163
Transcript of MISSOURI DEPARTMENT OF HEALTH AND SENIOR...
MISSOURI DEPARTMENT OF HEALTH AND SENIOR SERVICESSTATE PUBLIC HEALTH LABORATORYBREATH ALCOHOL PROGRAM
INTOX EC/IR II MAINTENANCE REPORT REPORT #3
Complete this report at the time of the regular monthly preventive maintenance check (not to exceed 35days). Complete this report whenever the instrument is serviced or repaired and whenever it is placedinto service. Retain the original and send a copy within 15 days to the Breath Alcohol Program, DHSS.INTOX EC/IR II SN
12680
NAME OF AGENCY
SLMPD BAT VAN
DATE OF INSPECTION
04/03/2017
LOCATION OF INSTRUMENT (STREET AND CITY)
2150 S 59th St ST LOUISTIME OF INSPECTION
14:23 CDTCHECKLIST: Place a mark in the box by each item if found to be satisfactory or is operating within
established limits. (Write in observed values where determined) . Unmarked items must be corrected
before using instrument.
DIAGNOSTIC RECORD
' BLANK CHECK EICO2 CHECK
taFC 1 TEMP 'MELON CHECK
OSRC TEMP EFCB CHECK
raDET TEMP ta RC COMP CHECK
EIBT TEMP ta CRC CAL CHECK
EISTD 2 TEMP ETRINT TEST
'METH CHECK
BREATH ANALYZER ACCURACY STANDARDS
OSIMULATOR SOLUTION EICOMPRESSED ETHANOL-GAS MIXTURE
IMSTANDARD SUPPLIER INTOXIMETERS LOT# AG531302 EXP. DATE 11/09/2017
SIMULATOR TEMP (34°C +0.2°C) SIMULATOR S/N SIMULATOR EXP DATE
OCALIBRATION
Runandused.
CHECK - (ONLY ONE STANDARD IS TO BE USED PER MAINTENANCE REPORT)
three tests using a standard solution. All three tests must be within +5% of the standard valuemust have a spread of .005 or less. Mark the box corresponding to the standard solution being
(PRINTOUT ATTACHED)
0.10% STANDARD - MUST READ BETWEEN 0.095% AND 0.105% INCLUSIVE
0.08% STANDARD - MUST READ BETWEEN 0.076% AND 0.084% INCLUSIVE
0.04% STANDARD - MUST READ BETWEEN 0.038% AND 0.042% INCLUSIVE
TEST 1 - 0.079 g/2101, TEST 2 ,'.' 0.079 g/210L TEST 3 — 0.078 g/210L
INDICATE THE NUMBER OF BREATH TESTS /N THE FOLLOWING RANGES SINCE THE LAST MAINTENANCE REPORT:
REFUSALS 0 0-.04 0 T.05-.09 0 .10-.14 0 .15-.19 0 OVER .19 0
=ST AN( NEW PARTS AND DBSCRIBEMY— AUTEMTION OR MODIFICATIO1TSATISFACTORILY AND WITHIN ESTABLISHED LIMITS (USA OTHER SIDE
INSPECTING OFFICER•..
THAT— WAS MADE TO khSTORE THE INMITRIEN' TO OPERATEIF NECESSARY).
CHRISTIAN, SCOTTT . y 6 4 I ? MB
250291EXPIRA1ION DATE
12/02/2017•ihbhPHOME NUMBER
(314 ) 444-5345
RETURN COMPLETED REPORT TO THE:Breath Alcohol Program, Missouri Department of Health and Senior Services,Southeast District Office, 2875 James Blvd, Poplar Bluff, MO 63901
MO 580-2899 AN EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYERservices provided on a nondiscriminatory basis
LAB 163
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MISSOURI DEPARTMENT OF HEALTH AND SENIOR SERVICESSTATE PUBLIC HEALTH LABORATORYBREATH ALCOHOL PROGRAM
INTOX EC/IR II MAINTENANCE REPORTComplete this report at the time of the regular monthly preventive maintenance check (not to exceed 35
days). Complete this report whenever the instrument is serviced or repaired and whenever it is placed
into service. Retain the original and send a copy within 15 days to the Breath Alcohol Program, DHSS.
REPORT #3
INTOX Ec/IE II SN
12681NAME OF AGENCYSLMPD
DATE OF INSPECTION04/03/2017
LOCATION OF INSTRUMENT (STREET AND CITY)1915 OLIVE ST LOUIS
TIME OF INSPECTION
1502 CDTCHECKLIST: Place a mark in the box by each item if found to be satisfactory or is operating within
established limits. (Write in observed values where determined). Unmarked items must be correctedbefore using instrument.
ElDIAGNOSTIC RECORDElBLANK CHECK EICO2 CHECK
OFC 1 TEMP'AFC 1 TEMP IMFLOW CHECK
IMSRC TEMP EIFCB CHECK
'MET TEMP EICRC COMP CHECK[TT TEMP MCRC CAL CHECK
EISTD 2 TEMP EIPRINT TESTMETH CHECK
BREATH ANALYZER ACCURACY STANDARDS
SIMULATOR SOLUTION MCOMPRESSED ETHANOL-GAS MIXTUREElSTANDARD SUPPLIER INTOXIMETERS LOT# AG531302 EXP. DATE 11/09/2017
OSIMULATOR TEMP (34°C +0.2°C) SIMULATOR SiN SIMULATOR EXP DATE
MCALIBRATION CHECK - (ONLY ONE STANDARD IS TO BE USED PER MAINTENANCE REPORT)
Run three tests using a standard solution. All three tests must be within +5% of the standard valueand must have a spread of .005 or less. Mark the box corresponding to the standard solution beingused. (PRINTOUT ATTACHED)
P0.10% STANDARD - MUST READ BETWEEN 0.095% AND 0.105% INCLUSIVE0.08% STANDARD - MUST READ BETWEEN 0.076% AND 0.084% INCLUSIVE
0.04% STANDARD - MUST READ BETWEEN 0.038% AND 0.042% INCLUSIVE
TEST 1 0.080 g/210L I TEST 2 0.080 g/210LTEST 3 0.080 g/210L
INDICATE THE NUMBER OF BREATH TESTS IN THE FOLLOWING RANGES SINCE THE LAST MAINTENANCE REPORT:
REFUSALS 0 0 - .04 3 0 1 . 05- . 0 9 0 .10-.14 3
ZATIO l'HAT WAS mAnE
.15 - .19 0 OVER .19 0
!STORE THE INSTRUMEN'T 0 OPERATELIST ANY-W8W PARTS AND DESCRIBE ANY ALTftEXTME OR MODIFICATION tHkr WAS MADE TO RATORE THE imsYkUmENTITUTUMMTZSATISFACTORILY AND WITHIN ESTABLISHED LIMITS (USE OTHER SIDE IF NECESSARY).
INSPECTING OFFICE*
T A 5./t/A7J,--,tz/Z/V10-
fliF 11 NUMBEli
250291RXPIEAXION DATZ12/02/2017
1 TELEPHONE NUMBER( 314 ) 444-5345
TT
RETURN COMPLETED REPORT TO THE:Breath Alcohol Program, Missouri DepartmentSoutheast District Office, 2875 James Blvd,
of Health and Senior Services,
Poplar Bluff, MO 63901
MO 580-2899 AN EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYERservices provided on a nondiscriminatory basis LAB 163
MISSOURI DEPARTMENT OF HEALTH AND SENIOR SERVICESSTATE PUBLIC HEALTH LABORATORYBREATH ALCOHOL PROGRAM
INTOX EC/IR II MAINTENANCE REPORTComplete this report at the time of the regular monthly preventive maintenance check (not to exceed 35days). Complete this report whenever the instrument is serviced or repaired and whenever it is placedinto service. Retain the original and send a copy within 15 days to the Breath Alcohol Program, DHSS,INTOX EC/IR IT SN
12683NAME OF AGENCY
SLMPDDATE OF INSPECTION
04/03/2017LOCATION or INSTRUMENT (STREET AND CITY)
5120 CLAYTON RD ST LOUISTIME OF INSPECTION
1344 CDTCHICHLIST: Place a mark in the box by each item if found to be satisfactory or is operating withinestablished limits. (Write in observed values where determined). Unmarked items must be correctedbefore using instrument.MD/AGNOSTIC RECORD
EIBLANK CHECK 0002 CHECK
ETC 1 TEMP LiFLOW CHECK
EISRC TEMP IDFCB CHECK
ODET TEMP IMICRC COMP CHECK
EIBT TEMP • CRC CAL CHECK• STD 2 TEMP EIPRINT TEST
'METH CHECK
BREATH ANALYZER ACCURACY STANDARDS
OSIMULATOR SOLUTION F1C0MPRESSED ETHANOL-GAS MIXTURE
ESTANDARD SUPPLIER INTOXIMETERS LOT# AG531302 EXP. DATE 11/09/2017
SIMULATOR TEMP (34°C +0.2°C) SIMULATOR S/N SIMULATOR EXP DATE
EICALIBRATION CHECK - (ONLY ONE STANDARD IS TO BE USED PER MAINTENANCE REPORT)
Run three tests using a standard solution. All three tests must be within +59s. of the standard valueand must have a spread of .005 or less. Mark the box corresponding to the standard solution beingused. (PRINTOUT ATTACHED)
illA 0.10-gs STANDARD - MUST READ BETWEEN 0.095% AND 0.105% INCLUSIVE
0.08% STANDARD - MUST READ BETWEEN 0.076% AND 0.084% INCLUSIVE
0.04% STANDARD - MUST READ BETWEEN 0.038% AND 0.042% INCLUSIVE
TEST 1 -,- 0.079 g/210L TEST 2 '7,' 0.079 g/210L TEST 3 1"' 0.079 g/210L
INDICATE THE NUMBER OF BREATH TESTS IN THE FOLLOWING RANGES SINCE THE LAST MAINTENANCE REPORT:
REFUSALS 6 0-.04 0 .05-.09 0 .10-.14 1 .15-.19 1 OVER .19 3LIST ANY NEW PARTS AID DESCRIBE ANY ALTERATION OR MODIPTCATIOSATISFACTORILY AND WITHIN ESTABLISHED LIMITS (USE OTHER SIDE
INSPECTING OVFICER
'AilEllWillir,dip _
THAT WAS MADE TO RE TORE THEiN5TRIJM5NTTO OPERATE
zr NECESSARY).
.. , ,..- -emm-sTIAA,
TY.v,,..u1.1.
P,../■,' 1.16 R
250291•XPIRATION DATT12/02/2017
TELE.MONE NUMBER
( 314 ) 444-5345
RETURN COMPLETED REPORT TO THE:Breath Alcohol Program, Missouri Department of Health and Senior Services,
Southeast District Office, 2875 James Blvd, Poplar Bluff, MO 63901
-- -- ---„ -- -----N EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYERservices provided on a nondiscriminatory basis LAB 113
Alms
Customer NameExclusive SupplierIntoximeters, Inc.2081 Craig RoadSt. Louis, Mo 63146
Airgas USA LLC (LAB)
3500 Bernard Street
St. Louis, Mo. 63103
Ph: (314) 533-3100
Fax: (314) 533-7328
Certificate of Analysis
Test Date: 10-Nov-2015
Lot # AG531302 Model 108cacd
Exp. Date Cyl. Type Component Certified Concentration9-Nov-2017 108 Ethanol 0.080 ± 0.002 BrAC (218 ppm)
Nitrogen Balance
Certification Traceable to N.1.S.T. RGM Ethanol Standards:
Serial No. Concentration Serial No. ConcentrationEB0010581 391.8 ppm EB0010603 392.6 ppmEB0010570 269.6 ppm EE0010559 258.9 ppmEB0010285 209.0 ppm EB0010596 208,9 ppmEB0010561 103.7 ppm EB0010562 104.9 ppmEB0010681 52.22 ppm EB0010579 52.94 ppm
Analytical Method: NOIR
Digitally signed by Quality ControlDate: 2016.11.10 09:43:23 -06:00Reason: Dry gas standard certification of analysisLocation: Alrgas USA LLC (Lab)
Analyst: Ake.Rod Marsala
ISO 17025:2005 A2LA accredited. Certificate Number 2969.01
Pace 1 of 1
Ai rga sCustomer NameExclusive SupplierIntoximeters, Inc.2081 Craig RoadSt. Louis, Mo 63146
Airgas USA LLC (LAB)
3500 Bernard Street
St, Louis, Mo, 63103
Ph: (314) 533-3100
Fax: (314) 533-7328
Certificate of Analysis
Test Date: 10-Nov-2015
Lot # AG531302 Model 108cacd
Exp. Date Cyl. Type Component Certified Concentration9-Nov-2017 108 Ethanol 0,080 ± 0.002 BrAC (218 ppm)
Nitrogen Balance
Certification Traceable to N.I.S.T. RGM Ethanol Standards:
Serial No. Concentration Serial No. ConcentrationEB0010581 391.8 ppm EB0010603 392.5 ppmEB0010670 259.8 ppm EB0010559 268.9 ppmEB0010285 209.0 ppm EB0010595 208.9 ppmEB0010561 103.7 ppm EB0010562 104.9 ppmEB0010681 62.22 ppm EB0010579 52.94 ppm
Analytical Method: NDIR
Digitally signed by (Nality ControlDate: 2015.11.10 09:43:23 -06:00Reason; Dry gas standard certification e analysisLocation: Airges USA LLC (Lab)
Analyst:Rod Marsala
ISO 17025:2005 A2LA accredited. Certificate Number 2989.01
Paae 1 of 1
AirgasCustomer NameExclusive Supplierintoximeters, Inc.2081 Craig RoadSt. Louis, Mo 63146
Airgas USA LLC (LAS)
3500 Bernard Street
St. Louis, Mo, 63103
Ph: (314) 533-3100
Fax: (314) 533-7328
Certificate of Analysis
Test Date: 10-Noy-2015
Lot # AG531302 Model 108cacd
Exp. Date Cyl. Type Component Certified Concentration9-Noy-2017 108 Ethanol 0.080 ± 0.002 BrAC (218 ppm)
Nitrogen Balance
Certification Traceable to N,I.S.T. RGM Ethanol Standards:
Serial No. Concentration Serial No. ConcentrationEB0010581 391.8 ppm EB0010603 392,5 ppmE130010570 259.8 ppm EB0010559 258.9 ppmE130010285 209.0 ppm EB0010595 208.9 ppmEB0010561 103.7 ppm EB0010582 104.9 ppmEB0010881 52.22 ppm EB0010579 52.94 ppm
Analytical Method: NIDIR
Digitally signed by Quality ControlDate: 2015.11.10 09:43:23 -06:00Reason: Dry gas standard certification of analysisLocation: Airgas USA LLC (Lab)
Analyst:Rod Marsala
ISO 17025:2005 A2LA accredited. Certificate Number 2989.01
Pace 1 of 1
STATE OF MISSOURIDEPARTMENT OF HEALTH AND SENIOR SERVICES
BREATH ALCOHOL PROGRAM
PERMITTYPE II
SCOTT CHRISTIANis hereby authorized to instruct and supervise operators, train instructors, inspect, calibrate, perform field service and repairs,and operate the following breath analyzer(s):
INTOX EC/IR IIfor the determination of the alcoholic content of blood from a sample of expired air. Permit issued under the provisions of sections577.020 through 577.041, RSMo and 306.111 through 306.119 RSMo.
DATE 12/2/2015
NUMBER 250291
EXPIRES 12/2/2017
MO 5n4771 (6-10)
1^)&DIRECTOR OF STATE PuBpp HEALTH LABORATORY
DIRECTOR OF DEPARTMENT OF HEALTH AND SENIOR SERVICESLAB-4 (136-10)
