Air Water Complaint Form

Form
State of California
Department of Food and Agriculture
air/water complaint form
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:
 
    
 
   
                
       

 
 

 
 
Enter the business information:
 
  

   
 
ADDRESS 
 
 
CITY 
     

 
   
DATE 
   
DESCRIBE YOUR COMPLAINT USING CHECK BOXES AND ADDING REMARKS BELOW



 
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.