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STATE OF CALIFORNIA <br />8CIA 6016 <br />(Rev. 012018) <br />Ckk,;-)J <br />0EPARTMENT OFJUSTICE <br />REQUesT FOR LIVEPACE In, <br />App)+cant Submission <br />SCAN SERVICE <br />CA0301900 <br />v <br />ORI (dace 85aignetl <br />by 00J) <br />REGISTRATION APP. FOR RSP <br />PERMIT <br />Tu�tfiorTZeTXP—Prcant <br />ype o'Tlcense aryl r-ir.7n_�-.--,,.� __._ <br />ype <br />SANTA ANA POLICE DEPARTMENT <br />Agency Authorized to Receive Criminal Record Information <br />60 CIVIC CENTER PL.A7A <br />Street Address or P.O. Bou <br />SANTA ANA <br />CA 92702 <br />Other Name <br />(AKAor Arias) aL sC"`---- <br />;—;7 <br />Sex ❑ Male iv Female <br />t eig <br />Place �irth (Stale or Cour}ry) <br />Seca�Sod�PAPUA <br />� L_ <br />NomeSU - <br />Address Sheat Address ori O. Box <br />Your Number: <br />OCA wumher (Agency Identifying Numb.) <br />If re -submission, list original ATI number: <br />(Must provide proof of rejection) <br />Employer (Additional response for agencies specified by statute): <br />�Iltxuyul Plants <br />State ZIP Code <br />Live Scan Transaction Completed By: <br />Da. <br />A06020 <br />ai o e (Ive-d gif co a ass gne <br />A.PEZESHKPOUR <br />con ac Name (mandatory for all school submissions) <br />-(714) 667-2700 <br />Guinea lelepnoneNum e-6 r <br />i .SPS <br />r14,Wame <br />I e nala 3u� <br />Suffix <br />m9erl ��r <br />Bluing <br />Number <br />Agency gNum ar) <br />Misc. <br />Number <br />(timer loretnI a110e Numhaq <br />ciVtE P�� <br />Level of Service: ® OOJ ❑ FBI <br />riginal A umber — <br />a11 tie klivu digit c e assigns y ) <br />Telephone Number (optional) <br />GregoryA Harris VUS �6-- 16 -- 7o I <E� <br />Name of Operator Date <br />LK acnra NORM "CQUKfY � 4ly' M) 3G 5/4LQD � <br />Transmitting Agency LSIO ATI Number <br />yJ0— <br />Amount <br />— <br />Amount Collected/Billed <br />ORIGINAL- Live Scan Operator SECOND COPY - Applicant THIRD COPY of needed)- Requeating Agency <br />