Form G58 (Rev.1)
AGREEMENT TO PAY PARKING FEE
STATE OF CALIFORNIA
DEPARTMENT OF GENERAL SERVICES
Transportation Service
Date ____________________________________________________________ Time ____________________ AM PM
The undersigned hereby acknowledges that on the date and at the time indicated hereon he was without funds to pay the parking fee of $__________, which said amount he acknowledges to be the correct amount due in consideration of his having parked on State property for which a fee is payable.
The undersigned also acknowledges his obligation to pay the said fee to the State Garage shown below within five (5) calendar days from the date above or be subject to citation for violation of Section 13160 of the Government Code and Section 21113 of the California Vehicle Code.
___________________________ | ||
(Signature) | ||
___________________________ | ||
(Street Address) | ||
___________________________ | ||
(City) | ||
___________________________ | ||
(Driver's License No.) | (Expires) | |
___________________________ | ||
(Witness) |
White--Section copy
Canary--Accounting Officer copy
(GARAGE STAMP) Pink--Customer copy
39693-999-756 (404 2-65 25 QUAD 1 OSP Green--Garage copy
Cal. Code Regs. Tit. 2, § 1205