Fillable Massachusetts State Police - Crime Laboratory - Breath Test Record Request Form 9510

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Massachusetts State Police - Crime Laboratory - Breath Test Record Request Form 9510

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DEPARTMENT OF STATE POLICE
CRIME LABORATORY
OFFICE OF ALCOHOL TESTING
857-377-3035 Fax
BREATH TEST RECORD REQUEST FORM
(version 4.11.2016)
ARREST INFORMATION
Defendant:
(L,F, MI)
License # & State: DOB:
Arresting Dept: Date of Arrest:
Court: Docket No:
Note: Attach a copy of the Police Report and the Breath Test Report Form
REQUESTED BY
Name: Telephone:
Agency: Fax:
Street Address
City: State Zip:
Date of Request: Court Date:
RECORDS REQUESTED
90 – 24 Record: Includes OAT breath test data for the defendant.
Periodic Test Record: Includes OAT periodic test data from calibration standard tests initiated by the
department OIC or agency prior to the defendant’s breath test.
Calibration and Verification Records: Includes OAT testing data conducted by OAT Forensic
Scientists.
Certification Summary: Includes OAT certification/expiration date and Certifying Chemist.
All records will be sent to the clerk’s office along with a business records affidavit.
*BREATH TEST RECORD REQUEST*
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Massachusetts State Police - Crime Laboratory - Breath Test Record Request Form 9510

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Completed 22 May 2020

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