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r <br />Narnc: Last First Middle <br />A4 <br />DOB: <br />§dace /lea: <br />W <br />lies. Address: tit} <br />State <br />zin <br />lies. Phone: <br />Work f'l one: <br />IF <br />Entering in or rising all City of Eugene parrs, open spaces or facilities. <br />The basis for this Notice of Restriction of Use is that on you violated Section <br />0 4 2 ) <br />of the Park. <br />and Open Space Rules, and/or Section of the Eugene Code, 1971, and /or ORS To wit, you: <br />PAQ-?, 11lo- - <br />M� <br />(Description of the violation.) <br />17 nours Ilexclusive 01 WeeKeHUSY 01 FMCIpt 011 Me request 177 17777171g 77 1,777 11717177771 Mai Ing M7 "777737 LJ77771,77 win <br />consider testimony from you, City personnel involved in the incident that resulted in this Notice, and other 7witnesses to I <br />ritorm <br />incident, The Division Director may exclude anyone, other than you and those presenting testimony, from the informal 1hearin <br />This Notice shall remain in effect p <br />This Notice of Exclusion was delivered to the person named at the top of this Not _ the date and time shown above by: <br />s <br />(Stgtf `ure Vperson issuing/delivering notice) <br />I hereby acknowledge receipt of the above Notice on the date and time indicated above. <br />( ignature of person being issue i notice) <br />White Copy: Public Works Green Copy: File Yellow Copy: Report Copy Pink I Recipient Gold Copy: Officer Appeal notice Rev. 04103 <br />