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Request to Prohibit Smoking on Adjacent Rights-of-Way (Opt-In Request)
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This form has been modified since it was saved. Please review all fields before submitting.
Please use this form to request non-smoking locations on adjacent public rights-of-way for properties that are places of employment outside of the downtown core.
*There are no fees associated with this request.
1. Requester/Property Owner Information
First Name
*
Last Name
*
Type of property where smoking is currently prohibited
*
Street Address
*
City
*
State Code
*
ZIP
*
Email
*
Phone
*
2. Requested Non-Smoking Location
*
Please attach a map, photograph, or diagram showing the right-of-way area(s) adjacent to the property where you are requesting that people be prohibited from smoking.
3. Impacts to Neighboring Properties
*
Are there designated smoking areas on your property?
Yes
No
Attach File
If no, please attached a map, photograph, or diagram showing the neighboring properties where smoking is unrestricted.
4. Electronic Signature
I certify that I am the owner or an authorized representative of the above-referenced property. I acknowledge that the City approving my request to prohibit smoking on adjacent rights-of-way does not alleviate my responsibility to comply with all other applicable local and state laws, including Eugene Code 6.225 – 6.240 and Administrative Order No. 21-18-07. I also acknowledge that the City approving my request to prohibit smoking on adjacent rights-of-way does not obligate the City, including the Eugene Police Department, to take any specific action to enforce the approved smoking prohibition.
Full Name
*
Date/Time
*
Date/Time
Date/Time
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