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t1- <br />Name, Last First Middle <br />DOR:� <br />Race/Sex: <br />0, &0 - 3 ft Pj 1i <br />L) <br />a w <br />Res. Addres city <br />State <br />Zip <br />Pes. Phone <br />Work Phonc: <br />kAwo-c lol <br />Under the authority of Administrative Order No. 5H-03-24-F and Park and Open Space Rule R-1.005(3), you are here�5e <br />notified that you are prohihited from (check box): <br />N1911 Entering in or using all City of Eugene parks, open spaces or facilities. <br />05t <br />The basis for this Notice of Restriction of Use is that on you violated Section Vii, 8 of the Park <br />and Open Space Rules, and/or Section of the Eugene Code 1971 and/or ORS To wit, yow <br />L__ , , <br />J <br />n2cl<0 5 AIC'R 8MA <br />(Description of the violation.) <br />This restriction or use is effective beginning on C O N I 1 9 4 and shall remain in effect until <br />If you enter in or use any City of Eugene park, opera space or facility during the effective period of this Notice, you may be <br />arrested and charged with criminal trespass in the second degree. <br />The Division Director shall schedule a time and place for the informal hearing to be conducted, which shall be not more th <br />72 hours (ex cl usive o l dq) of receipt of the request for hearing. At the in formal hearing the Divisi on Director w il I on <br />I <br />eonsider testimony from you, City personnel involved in the incident that resulted in this Notice, and o1her witnesses to t <br />incident. The Division Director may exclude anyone, other than you and those presenting testimony, from the informal hearin <br />This Notice shall remain in effect pending any requested hearing. I <br />This Notice of Exclusion was delivered to the person named at the top of this Notice at the ate and time shown above by: <br />(. V�nature of person issuin ffdel iti•e *rinnot ice) <br />I hereby acknowledge receipt of the above Notice on the date and time indicated above. <br />(Signa[uVf person nbeing issued the notice) <br />Whi to Copy Pub Works Green Copy: File 4 ellow Copy: Report Copy Pink Ck9y: kc6picot [fold Cupy Officer Appeal no ice Rev, 041103 <br />