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Gasoline Complaint Form


Please note your Name and Telephone number are confidential.



 
Please indicate type of complaint: (Required)





     




















 



Grade/Octane of fuel purchased:

Do you have a receipt:


Did you pay by credit card or cash:


Does the receipt price match the price on the pump:


Were you charged the amount shown on the pump:


Did you speak to the clerk at the gas station:



Maximum number of characters: 2,000


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