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STATE OF CALIFORNIA <br /> BCI1 6016 DEPARTMENT OF JUSTICE <br /> � <br /> (ong.4101;rev.6109) <br /> -� REQUEST FOR LIVE SCAN SERVICE <br /> Applicant Submission <br /> CA0390500 PERMIT <br /> ORI(code assigned by DOJ) Authorized Applicant Type <br /> Type of License/Certification/Perm it_$Working Title (Maximum 30 characters-if assigned by DOJ,use exact title assigned) <br /> Contributing Agency Information: <br /> STOCKTON POLICE DEPARTMENT 17207 <br /> Agency Authorized to Receive Criminal Record Information Mail Code(five-digit code assigned by DOJ) <br /> 22 E MARKET ST DIANA GONZALEZ <br /> Street Address or P.O.Box Contact Name(mandatory for all school submissions) <br /> STOCKTON CA 95202 (209)937-8422 <br /> City State ZIP Code Contact Telephone Number <br /> - <br /> Applicantlnforrnation: <br /> a�ckvIn)ben IS <br /> Last Name first Name Middle Initial Suffix <br /> Other Name <br /> (AKA or Alias) Last First Suffix <br /> 0,31 )1) Sex ❑ Male female 3 6 <br /> Date of Birth ,/� �7 Drivel's License Number <br /> ,S� 13 C) I•l�Q�1 Ct L Billing t V 0 0 <br /> Height Weight ye Color Hair Color Number <br /> !L nI64u 15-f- Sic.- �-f 3 T Misc. (Agency Billing Number) <br /> Place of Birth(State or Country) Social Security Number Number <br /> (other identification Number) p <br /> Home 13,)22 J N w,,Ison UDC- { Liz coon CII CI <br /> Address,.__StreetAddress or P.O.Box City State ZIP Code <br /> Your Number: Level of Service: [X1 DOJ ❑ FBI <br /> OCA Number(Agency Identifying Number) <br /> If re-submission, list original ATI number: Original ATI Number <br /> (Must provide proof of rejection) <br /> Employer(Additional response for agencies specified by statute): <br /> Employer Name Mail Code(five digit code assigned by DOJ <br /> Street Address or P.O.Box <br /> City State ZIP Code Telephone Number(optional) <br /> Live Scan Transaction Completed By: <br /> Name of Operator Date <br /> Transmitting Agency LSID ATI Number Amount Collected/Billed <br /> ORIGINAL-Live Scan Operator SECOND COPY-Applicant THIRD COPY(if needed)-Requesting Agency <br />