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Oregon Department of Agriculture

Department

FUEL COMPLAINT

Please fill out the following information...then click "SUBMIT".

Reason(s) for Complaint:
Your Name:
	(Name)
	(Address)
	(City, ST ZIP)	,
	(Work Phone)
	(Home Phone)
	(email)
FUEL PURCHASE INFORMATION Station where purchased:
	(Name)
	(Company/Brand)
	(Address)
	(City, ST ZIP)	,
	Date of Purchase:
	Time of Purchase:
	Payment Method:
	Name or Description of Attendant:
	Type of Fuel:
	Octane of 'Other':
	Pump Location:
	Did Pump Start at Zero?:
	Comments:
VEHICLE INFORMATION
	Vehicle Make:
	Model:
	Body Style:
	Year:
	Manufacturers Tank Capacity:
	By clicking the Submit button below I agree to the following statement: I acknowledge and agree that this complaint will become part of our permanent records. This form is also subject to Oregon's Public Records Law and may be disclosed to persons who request to review its contents. As such, it may be released to the business or person about whom you are complaining, members of the public, or other agencies if requested.

Quick ag links

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FUEL COMPLAINT

Your Name:

FUEL PURCHASE INFORMATION

VEHICLE INFORMATION