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z <br />Narne Last Middle <br />D013' <br />Race Sex: <br />�j <br />Res. Address: Citv State <br />Zip <br />Res. Phone: <br />Work Phone: <br />AJ <br />Under the authority. 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 (check box). <br />Entering in or using all City of Eugene parks, open spaces or facilities. <br />X <br />The basis for this Notice ofRestriction of Use is that oil you violated Section 61 /5E V the Park <br />and Open Space Rules, and/or Section of the Eu gene Cod c, 1971, and/or 0 R S To wit, you: <br />(Description cif the violation.) <br />This restriction of use is effective beginning on 1P L m and shall reain in eff u <br />ect ntil <br />L <br />if you enter in or rise any City of ELIgCTie park, open space or facility during the effective period of this Notice, you may he <br />arrested and charaed with criminal trespass in the second degree. <br />Pursuant to Park and Open Space Rule R- 1.074 VOU 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 C irector ( 'the Division Director") <br />within 48 hours (exclusive of weekends) ot'receipt ofthiq Notice it 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 weekends) of receipt ofthe request I - 'or hearing, At the inforr hearing the Division Director will only <br />consider testimony from you, City personnel involved in the incident that resulted in this Notice, and other witriesses lo the <br />incident. 'ne Division Director may exclude anyone, other than yen and those presenting testimony, I "rorn the informal hearing, <br />This Notice shall remain in effect pending any requested hearing. <br />This Notice of Exclusion was delivered to the pet narned at the top of this Notice - i - ' I ' date and tame shown above bv: <br />V U <br />igna to re of person issuing/delivering notice) <br />I hereby acknowledge receipt of the above Notice on the date and time indicated above. <br />(Signature of'person being ISSUed the notice) <br />Whi L, Copy: Pulflic Works Green Copy: File yd I ow Copy: Reporl Copt Pink (`op Ruq)icno (Jok] Copy Officer App•fl nuke Rev 04 :0 " <br />