NCDA Fuel Quality Complaint Form
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Complaint
Complaint:
Brand Name:
Pump Number:
Date of Puchase:
Time of Purchase:
Amount Purchased:
Do you have a receipt?
Was your car towed?
Has your car been worked on?
Estimated Cost of Repairs:
Have you notified the station of your complaint?
Do you have a special sample of fuel from your vehicle that you would like us to test?
Please note that we require approximately one quart of the sample in order to complete a full laboratory analysis.
Contact
Name:
Address:
Phone:
Email:
Complainant
Name:
Title:
Address:
Phone:
Email:
Preferred Contact Method: