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NOTICE OF RESTRICTION OF USE <br />and Notice of Right to Appeal <br />DATE: 2A JJ3 TIME: 7,yy AA, CASE <br />LOCATION (PARK/OPEN SPACE): Fr6,,, TjV POW <br />H <br />Name: Last First Middle <br />DOB:)Race/ <br />01 <br />13 to 1-F.0 �X <br />� + o <br />LU /°''t <br />Res. Address: City <br />State <br />Zip <br />Res, Phone: <br />Work Phone: <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 />A, Entering in or using all City of Eugene parks, open spaces or facilities. <br />U <br />The basis for this Notice of Restriction of Use is that on ,,;73 , you violated Section /j 00 i 4 of the Park <br />and Open Space Rules, and/or Section q I qct 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 a7,3 J:�, and shall remain in effect until 3 <br />If you enter in or use any City of Eugene 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 an informal hearing to contest this Notice. A request for an <br />informal hearing must be made in writing and flied 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 />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 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, from the informal hearing. <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 of this Notice at thXjafe and time shown above by: <br />I —A< Y/fl <br />( 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 />White Copy: Public Works Green Copy: File Yellow Copy: Report Copy Pink Copy: Recipient Gold Copy: Officer Appeal notice Rev. 04103 <br />