North Carolina Department of Agriculture and Consumer Services
Standards Division
1050 Mail Service Center, Raleigh, NC 27699-1050
Marcus Helfrich, Director, (984) 236-4750
NCDA Fuel Quality Complaint Form
Search for the complaint location below (Use comma to filter by city)
Location #:
Complaint Location:
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Address:
Complaint
Complaint:
Brand Name:
Fuel Type:
Select Fuel Type
Gas
Diesel
Kerosene
Motor Oil
E15
Flex Fuel
Biodiesel
Tractor Hydraulic Fluid
Other
Gas Grade:
Select Gas Grade
Regular
Plus
Premium
Diesel:
Select Diesel Type
Highway
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Biodiesel:
Pump Number:
Date of Puchase:
Time of Purchase:
Amount Purchased:
Do you have a receipt?
Yes
No
Was your car towed?
Yes
No
Has your car been worked on?
Yes
No
Estimated Cost of Repairs:
Have you notified the station of your complaint?
Yes
No
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.
Yes
No
Contact
Same as Complainant Contact Information
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Address:
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Phone:
Email:
Complainant
Name:
Title:
Address:
Select State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Federated States of Micronesia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
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New York
North Carolina
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North Marianas
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
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