Air Water Complaint Form

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:   NAME       STREET                     CITY    ZIP      PHONE:  EMAIL:    Enter the business information:   STATION NAME    TELEPHONE       ADDRESS      CITY    ZIP    COUNTY   Alameda Alpine Amador Butte Calaveras Colusa Contra Costa Del Norte El Dorado Fresno Glenn Humboldt Imperial Inyo Kern Kings Lake Lassen Los Angeles Madera Marin Mariposa Mendocino Merced Modoc Mono Monterey Napa Nevada Orange Placer Plumas Riverside Sacramento San Benito San Bernardino San Diego San Francisco San Joaquin San Luis Obispo San Mateo Santa Barbara Santa Clara Santa Cruz Shasta Sierra Siskiyou Solano Sonoma Stanislaus Sutter Tehama Trinity Tulare Tuolumne Ventura Yolo Yuba     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:   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.