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STATE OF CALIFORNIA <br />DEPARTMENT OF JUSTICE <br />a BGA 8016 <br />�' (Rev. 01)2616) <br />PAGE I of 2 <br />�; �(s <br />REQUEST FOR LIVE SCAN SERVBCE <br />Applicant Submission <br />CA0301900 " <br />PERMIT <br />CRI(cadaamgnedbyDOJ) <br />TUttFonzeUTP—Plcl"ant Ty—pe <br />REGISTRATION APP. FOR RSP <br />ype of License/Cerfifi—c5g—on efm1Y <br />Or Ing Ite Maxl mum'fOcharadere-i awlgn¢tl by DOJ, ase exactuneasaign¢dr' <br />Contributing Agency Information: <br />SANTA ANA POLICE DEPARTMENT <br />Agency Authorized to Receive Criminal Record Information <br />60 CIVIC CENTER PLAZA <br />Street Address or P.O. Box <br />SANTA ANA CA 92702 <br />City 9 aTe o e <br />Other Name <br />(AKAOr Alias) Last <br />Das/ f fB Sex ��M��ale��� ��❑ Female <br />FliI! n e'5� >�9'd,' —. <br />9 / g ye o or air olor <br />Place of Birth(Slate or Country) Social Security Number <br />Home `-'t 4 -I <.7 * 1 1 V I'f' GJ1 <br />Address Street Address or P.O. Box <br />Your Number: <br />OCA Number (Agency identifying Number) <br />If re -submission, list original Ail number: <br />(Must provide proof of rejection) <br />Employer (Additional response for agencies specified by statute): <br />Employer Name <br />State ZIPCode <br />Live Scan Transaction Completed By: <br />A06020 <br />a ode Ive- Igit co a assigne by D <br />A.PEZESHKPOUR <br />Contact Name (mandatory for all school submissions) <br />(7 14) 667-2700 <br />ontact aep one Number <br />. IA � <br />Fir <br />St Name N len aT— $uflix <br />17I `7 � V-iC I <br />f�nve7s cense Num er <br />Billing <br />Number <br />'(Agency aging NuMber) <br />Misc. <br />Number <br />(Other Idanllllcation Number <br />ulty i2tatE ZIP Code <br />Level of Service: M DOJ ❑ FBI <br />nein- 1 um er <br />a l e e ma ign co a assigne y <br />Telephone Number (optional) <br />Gregory A Harms VU5 <br />5-I S -dol � <br />Name of Operator Date <br />LpfiscrwNORM ORMCErrimmy Aur, M1�5`Zaa1D�4 <br />Transmitting Agency LSIO ATI Number Amount Collected/Billed <br />ORIGINAL- Live Scan Operator SECOND COPY -Applicant THIRD COPY (it needed) - Requesting Agency <br />