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2. Name
   Please fill in your contact information if you would like to be contacted.
3. Phone Number or Email Address
5. Address
6. City
7. Zip Code
9. Type of Complaint*
   -- Select One --Gas station complaintWeighing or measuring device complaintScanner overcharge complaintPackaging complaintFirewood complaintPricing advertisement complaintOther

   Please select the type of complaint.
10. Date and Time *
    Date and Time

    Date and Time
    Please give the date and time that the incident occurred.
12. Business Name*
14. Address1*
16. City*
17. Zip Code
19. Dispenser Number*
20. Grade*
    -- Select One --Regular (87)Mid (89)Plus (91)Diesel #2
22. Nature of Complaint*
24. Images
    Please include any photos that were taken.
Leave This Blank:


26. 1. Receive an email copy of this form.
27. Email address

    This field is not part of the form submission.

28. Submit Submit and Print

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