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� - I (-� ` <br />z <br />Name: F i r,4 Middle <br />l <br />DOK <br />Race/sex� <br />7 CS <br />� <br />Res, Address: <br />e <br />Zip <br />Res. Plionel <br />Work Phone: <br />Under the authorit) of Administrative Order No. 58-03-24-F and Park and Open Space Rule R-1.005(3), you are hereby� <br />notified that you are prohibited from (clieck box): <br />Entering in or using all City of Eugene parks, open spaces or facilities. <br />and Open Space Rules, and/or Section of the Eugene Code, 19'71, and/or ORS To wit, you: <br />ti <br />n <br />T y <br />Aw? <br />(Description of the violation.) <br />This restriction of use is effective beginning on m 0 \ �' _, and shall remain in effect until <br />wc,)\ <br />If you enter in Or Use any City ofFlugene park, open 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 />Pursuant to Park and Open Space Rule R-1,074 you are entitled to air 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 Directc)r ("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 lor the informal hearing to be conducted, which shall be not more than <br />72 hours (exclusive of weekends) 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, fro m the informal hearing. <br />This Notice shall remain in effect pending any requested hearing. <br />This Notice (if Exclusion was delivered to the person named at the top of this, Notice at the date and time shown above by: <br />(Signature of person issuingidelivering notice,) <br />I hereby acknowledge receipt of the above Notice on the date and time indicated above. <br />(Signature of" erson being issued the notice) <br />whil� CopY. PLIbi NC Wor (Ire�n Copy� I i ae yellow Copy: Roport Copy = Pink 4 up Recipjeni Gold COJA': Officer Appeal nolwe Rc�, 0416 71 <br />