Thank you for taking the time to complete this online form. Be sure to complete all of the information, which
will help us to investigate your concerns.
Name of Complainant:
Complainant's Email:
Please send me a copy of the results.
Phone Number:
Date of Complaint:
Firm's Name:
Address:
Device/Commodity:
(Examples: fuel pump, scale, scanner, package commodity)
Location of Device:
(Examples: pump 3, premium gas, 87 octane, scale in aisle 7, back counter)
Reason For Investigation:
500
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