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��q 5�1i <br />NOTICE OF RESTRICTION OF USE <br />and Notice of Right to Appeal <br />DATE: <br />LOCATION (PARK/OPEN SPACE): S 1<2,1n/9L 3 U776: - Z9, C CKt'Ys� ZA R £ <br />TIME: o q a® CASE #: !! ' <br />H <br />Name: Last First Middle <br />DOB: <br />Race /Sex• <br />Tzo-Tcn! �aH�✓�s(, <br />®3-17 <br />cod ah <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 />Entering in or using all City of Eugene parks, open spaces or facilities. <br />The basis for this Notice of Restriction of Use is that on you violated Section 1,610 of the Park <br />and Open Space Rules, and/or Section LA Eugene Code, 1971, and/or ORS . To wit, you: <br />(Description of the violation.) <br />j <br />This restriction of use is effective beginning on E �"(� , and shall remain in effect until <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 filed 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 the date and time shown above by: <br />&, D T sS <br />(Signature of person issuing /delivering notice) <br />I hereby acknowledge receipt of the above Notice on the date and time indicated above. <br />WAVLI E T4l-�Ij To S e - G 3 5S' <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 />