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Request to Prohibit Smoking <br />on Ad������tRights-of-Way <br />° <br />(Opt_Kn Request) <br />*Please complete, sign, and submit this Opt -In form to the City Manager's Office at 125 East 8th Avenue, <br />2nd Floor, Eugene, OR974U1,Attn: Opt -In Request. <br />*There are no fees associated with this request. <br />1. Requester/P rope rty Owner Information: <br />Name of Requester/Property Owner: <br />Type of property where smoking is currently prohibited: <br />Address: <br />City/Zip: <br />E -Mail Address: Phone: <br />2. Requested Non -Smoking Location: <br />Please attach amap, photograph, ordiagram showing the hgarea(s) adjacent 10the property <br />where you are requesting that people beprohibited from smoking. <br />3. Impacts to Neighboring Properties: <br />[]Yes Are there de�gnatedsmuNng areas onyour pnope�&��Yy? es �� ��Nu |fno, please attach amap, <br />photograph, or diagram showing the neighboring properties where smoking is unrestricted. <br />4. Signature: <br />| cc/dfv that | am the owner or an authorized representative of the above -referenced property. | <br />acknowledge that the City approving my request to prohibit smoking on adjacent rights-of-way docs not <br />alleviate my responsibility to comply with all other applicable local and state |ovvs including Eugene <br />Code 6225-6240 and Administrative Order No. 21-18-07. | also acknowledge that the City approving <br />my request to prohibit smoking on adjacent rights-of-way does not obligate the City, including the <br />Eugene Police Department, totake any specific action tn enforce the approved smoking prohibition. <br />Signature Date Print Name <br />The above request toopt-out nfthe Downtown Core smoking prohibition is: <br />11 Approved [] Denied <br />11 Approved with Modification(s <br />By: Date: <br />11Copy sent to BPS. <br />Smoking Prohibition Opt -in Request Form <br />