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Z <br />Name: Last First Middle <br />DOB, <br />acre/ Sex' <br />Gli'k <br />C1 a <br />Uj <br />Res. Address: City <br />State <br />Zip <br />Res. Phone: <br />Work Phone: <br />Il � I 11 Iq 111�1111 illill 11111 �illill 111 111 111111l 111 11 <br />Entering in Gr using all City of Eugene parks, open spaces or facilitil <br />X <br />The basis 1`6r this Notice of Restriction of Use is that on _�� f �, you violated Section tl�40�0161 4 Jof the Park <br />and Open Space Rules, and/or Section _ 26�c of the Eugene Code, 1971, and/or ORS -. To wit, you:_ <br />(,Description of the violation.) <br />This restriction of use is effective beginning on— q 117 and shall remain in effect until L)ej <br />If you enter in or use any City of ugene park open space or facility during the effective period of this Notice, you inky be <br />arrested and charged with criminal trespass in the second degree. <br />Pursuant to Park and Open Space Rule. R - D74 you are entitled to an informal hearing to contest this Notice. A request for an <br />informal hearing must be made in writing and riled 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 />I hereby acknowledge receipt of the above Notice on the date and time indicated above. <br />(Signature of person being issued the notice) <br />White Copy: Public Works Green Copy! Fihe Yel loo Copy: Report Copy Fink Copy : Rec ipi � nt Gold Copy: Officer Appeal notice Rev- NM3 <br />