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04� <br />NOTICE OF REs,rRICTICSN OF LJSE <br />and Notice (if Right to Appeal <br />DATE: KA -1 � it( TIME: 19 CASF,4: <br />I <br />LOCATION WARKIOPEN SPA() --# _M . ........ <br />NaTne: Last First Middle DOB, Rao"'Is <br />'I C ji'l 5 <br />Res. Adam ss: (:ity State Zip Res. Phone� Work, 11honro: <br />T14A.41,e 10 - — <br />Under the a uthority of Administrative Order No. 58-03-24-F a nd Pa rk and Open Space Rule Ili -1.005( ), you a re h ercby <br />notified that you are prohibited from (check box): <br />Entering in or using all City of Eugene parks, open spaces or facilities. <br />. . . .. .. . ....... . .. .......................... <br />The basis ftir this Notice of'Restriction oflJse is that on ycpu violated Section c Rark <br />. . ..... . .................. . - ----- ........... <br />and Open Space Rules, andk.pr Se rtit)n 111-10.7 ....... . .... of the Eugene (, I ode, 19''71, and/or OR I To Wilt, <br />. ............................ <br />f _, I . . . . . . . ...... . . . .......................................... <br />(Description of the, violation.) <br />A <br />This restriction of und n e <br />se is effective beginning on jI( I j-�—,, ashall remain iffect until <br />lifyou enter in or use any City of Eugene park, open space or I'acility during the effective period of this lqotuce, you rnay be <br />atrested and charged with criminal trespass in the second degree, <br />Pursuant to Park and Openlipace Rule R-1.074 you u are entitled to an informal hearing to contest this Notice°reqtte-9 f6r all <br />informal hearing must 'be made in writing and filed with the Flark-s & Open Space Divi„ on Director ("-the Divisk,)n Direicator") <br />within 48 1101ITS (exclusive ol'weekends) olf 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 informal hearing to be conducted, whi(.41 stvfll bc,� not mfjrc than <br />'72 hours (exclusive of weekends) of receipt of the request for hearing, At the Infort'nal hearing the Division Director wiH only <br />consider test runny from you, Oty p(..-,rsonncI involved in the incident that resulted in this Notice, and other witnesses to the <br />incident, The Division Dirccor may exclude anyone, other than you and those presenting festiniony, from the informai hiaearirlg. <br />This Notice shall remain in effect pending any requested hearing. <br />This Notice of'Exclusion was delivered to the person named at the top ofthis Noitice at t date and time shown abuve [.uy: <br />(Signature of person issuing/delivcring nollicic') <br />I hereby acknowledge receipt ofthe above Notice on the date and time indicated above. <br />ofperson being issm';d this, noilicie) <br />`A,hki ( op PIA- is Wrwk!; Ura en (:c:,py: File YelknGckjpyReport (-'Opy Pink Copy: Kec�ipiont Gold Cbjpy: Officer ApIpprm.fli noihtirr,, Kc W T, <br />