Admin Order 21-18-07 - Laserfiche WebLink

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Exhibit Downtown Core Smoking Prohibition Opt -Out Request *Please complete, sign, and submit this Opt -Out form tothe City Manager's Office at1Z5East 8m Avenue, 3"" Floor, Eugene, 0R97401,Attn: Opt -Out Request. *There are nofees associated with this request. 1. Requester Information: Name of Requester: Name of Downtown Core Private Establishment: Address: E -Mail Address: 2. Requested Smoking Location: City/Zip: Phone: Please attach a map, photograph, or diagram showing the right-of-way area(s) adjacent to your private establishment where you are requesting that people beallowed tosmoke. 3. Opt -Out Request (choose one) �� �� All Day �� 4fter9:0]p.m. 4. Signature | certify that | am an authorized representative of the above -referenced private establishment. | acknowledge that the City approving my request to aUmvv smoking within the downtown cone on adjacent rights-of-way does not alleviate my responsibility to comply with all other applicable local and state laws, including Eugene Code 622S-624Oand Administrative Order No. I1'18-07. | understand that in addition to the penalties provided in City [ode, any violation of the applicable regulations may result in the City revoking the permission granted me to allow smoking within the downtown core adjacent to the above -identified property. | agree to encourage patrons to use any cigarette disposal receptacle near the property provided by the City and | agree to work cooperatively with the City in placing the cigarette disposal receptacle in an optimum location for maximum usage. Signature Date Print Name The above request to opt -out of the Downtown Core smoking prohibition is: 0 Approved [] Denied [] Approved with Modification(s LN Dote: Downtown Core Smoking Prohibition Opt -Out Request Form 0copy sent mBPS.