Weights & Measures Consumer Complaint Form

Consumer Information

Name:	*
Address:
City:
State:	PA
Zip:
Phone #:	*
Email:	*

Facility Information

Facility Name:	*
Address:
City:	*

Purchase Information

Item Purchased:
Item Packaged:	Yes No
If Item Was Gasoline
Pump Number:
Octane Rating:
If Item Was Packaged
Package Size:
Package Code:
Manufactured By:

Complaint Details

Nature of Complaint: