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NariCE OF RESTRICTION OF US <br />DATE: <br />LOCATION (PARK/OPEN SPACE): <br />and Notice of Right to Appeal <br />TIME: <br />lae <br />CASE #- <br />C's <br />a ""', <br />7- <br />Name: Last First Middle <br />MW S vft 6U- <br />DOB: <br />e2— <br />Ra <br />Res, Address <br />City <br />State <br />Zip <br />Res. Phone <br />Work Phone <br />Under the authority of Administrative Order No. 58-03-24-F and Park and Open Space Role R-1.005(3), you are hereby <br />notified that you are prohihited from (check box): <br />Entering in or using all City of Eugene parks, open spaces or facilities. <br />I - <br />L1 <br />The basis for this Notice of Restriction of Use is that on 6 ------ you violated Section Y) fthe Park <br />and Open Space Rules, and/or Section q.110 of the Eugene Cod e, 1- 971, and/or ORS To wit, you: <br />Pursuant to Park and Open Space Rule 1-t -1,074 you are entitled to rata informal hearing to contest this Notice. A request lbran <br />informal hearing must be made in writing and filed with the Parks & Open Space Division Director ("the Division Director") <br />within 48 hours (exclusive of weekends) of receipt of this Notice at the following address: 1820 Roosevelt, Blvd., Eugene, OR <br />97402. <br />The Division Director shall schedule a time and place For the informal hearing to be conducted, which shall be not more than <br />72 hours (exclusive of week of receipt of the request for hearing, At the informal hearing the Division Director will only <br />consider testimony from you, City personnel involved in the incident that resulted in this Notice, and other witnesses to the <br />incident. The Division Director may exclude anyone, other than you and those presenting testimony, from the informal hearing. <br />This Notice shall remain in effect pending any requested hearing. <br />"this Notice of Excl usion was delivered to the person named at the top of this Notice at the date and t inge shown above by: <br />Tw <br />--------- ----- — ------ <br />(Signature ol'perwon issuing/delivering notice) <br />I hereby acknowledge receipt of the above Notice on the date and time indicated above, <br />— - - ------------------ <br />(Signature of p Irson being issued the notice) <br />White Copy Public Works Gmen Cupy: File 4°61ow Copyl ReporL COPY Pink Copvc R-c-cipient Guld Copy: Ofllo,!r Appeai ncAicc <br />