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z <br />Natrie: Last First Middle <br />C ' fy <br />DOB <br />rn <br />Res, Address (,sty <br />4 <br />Stta <br />zip <br />Res. Phone: <br />yy <br />Work Phone: <br />Under the authority of Administrative Order No. 58-03-24-F and Park and Open Space Rule 1 -1.0050). you are herehy <br />" otified that you are prohibited from (check box): <br />� <br />E�4 Entering in or using all City of Eugene parks, open spaces or facilities. <br />The basis for this Notice of Restriction of Use is that on you violated Section bf the Park <br />LWO <br />and Open Space Rules, and/or Section aqo)f the Eugene Code, 1971, and/or ORS To wit, yow— <br />( <br />(,Description of the violation.) <br />mqq-w� ­� "wf " <br />() 7FZIS , C3 (-­�' <br />This restriction of use is effective beginning on ( 6 and shall remain in effect until —Ca (0 2 d <br />i f y ou enter in or use any City of Eugene park., open space or facility during the e ITective period of this Notice, you may be <br />arrested and charged with criminal trespass in the second degree. <br />Pursuant to Park and Open Space Rule R- 1.074 you are entitled to an informal hearing to contest this Notice. A request for an <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 inform.al hearing to he conducted, which shall be not more than <br />I <br />of receija of tLe-L�uest for hearing. At the in forrual hearing the Division Director will oni <br />consider testimony From you, City personnel involved in the incident that resulted in this Notice, and other witnesses to the <br />incident, Tire. Divis ion Director may exclude anyone, other than you and those presenting testimony, frorn the in formal heart ng, <br />This Notice shall remain in effect pending any requested hearing. <br />This Notice of Fxcluqion was delivered to the person maned at the top of this Notice at the date and tinie shown above by: <br />�(' Yr'j I q <br />(Signature of person issuing delivering nctuce) <br />I hereby acknowledge receipt of the above Notice on the date and time indicated above. <br />- -------- - - - --- ?c ..... ...... .... <br />(Signature of person being issued the notice) <br />abitc Copy: Puhlw, Works Green Copy� File Yellow Copp Report Copy Pink Copy, Recipieiir Cold Copy Offim App pal nc4 im Rev- d 03 <br />