2. Name of the Complaint*

   1. Short Weight Product
   2. Short Measure Fuel
   3. Pump Number
   4. Premium

   1. Mid-Grade
   2. Regular
   3. Price Overcharge
4. Business Name*
6. Business Address
8. Street Address*
10. Apartment, Suite. or Building
12. City*
13. State*
14. Postal / Zip Code*
16. Describe the Situation Including as Much Detail as Possible*
18. If you wish to be contacted, please complete the following information:
20. Name
21. Email
23. Home Phone
24. Work Phone
26. Best Time To Call

    1. Home
    2. Work
27. Time of Day
29. Home Address
31. Street Address
33. Apartment, Suite, or Building
35. City
36. State
37. Postal / Zip Code
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39. 1. Receive an email copy of this form.
40. Email address

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41. Submit

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