Friday 07/25/2008   10:29 AM
Site Tree: Auditor Home: Online Forms
 
FUEL QUALITY COMPLAINT FORM
 Personal Information Test
Name:
First Last
Home Address:
City:
State:
ZIP Code:
Day Phone: Example: 513-422-5555
Evening Phone: Example: 513-422-5555
 
 Vehicle Information
Make:
Model: Example: Camry
Year:
 
 Station Information
Station Name:
Station Address:
City:
State:
ZIP Code:
 
If the address is unknown please describe location.
Example: "Corner of Niles and Dixie Highway."
 Incident Report
Date Occurred Example: 01/05/2001
Type of Gas:
Was the station notified of complaint? Yes No
 
Did vehicle require repairs? Yes No
If yes, please describe.
Cost of repairs: $
Were you reimbursed for repairs? Yes No
Additional Information/Comments: