Air & Water Form

State of California
Department of Food and Agriculture

1 (800) 356-7057
41-016a/w (Rev. 05/12)

California law requires that station operators provide free air and water to customers who purchase gasoline or diesel fuel.

After requesting free air and water from the attendant on duty, was the equipment activated or were you provided a token? If not, you were refused free air and water service. Please complete and submit online at www.cdfa.ca.gov/dms, or mail to: Division of Measurement Standards, 6790 Florin Perkins Road, Suite 100, Sacramento, CA 95828.

Please enter your information:
Please enter your name
NAME
Please enter your street
STREET
Please enter your City Please enter your zip code
CITY ZIP

Please enter your phone number
PHONE:

EMAIL:

Enter the business information:

Station Name is required STATION NAME	TELEPHONE
Please enter Station Address ADDRESS
Station City is required CITY ZIP	COUNTY
Date of Violation is required Please enter a valid date mm/dd/yyyy) DATE	TIME OF VIOLATION

DESCRIBE YOUR COMPLAINT USING CHECK BOXES AND ADDING REMARKS BELOW

Toll free number not posted

Air not available

Air not working

Air pressure gauge not available

Air not free with fuel purchase

Water not available

Water not working

Water not free with fuel purchase

CUSTOMER COMPLAINT:

Use either check boxes or remarks to describe your complaint.

IMPORTANT: Please read before submitting your complaint.

Without a fuel purchase there is no legal requirement that air and water be provided by the station.
Members-Only Discount Warehouse Retailers and Cardlock Facilities are not subject to this law.