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    Report Bad Gasoline

    First Name:     Last Name: 
    Address:  
    City:    State:    Zip:  
    E-Mail Address: 
    Daytime Phone #:         Evening Phone #:  
    Station Name:  
    Station Address: 
    Station City:  
    Pump #:  
    Date of Occurrence:  
    Regular:             Plus:         Premium: 
     
    Please give a brief explanation why you feel you received bad quality gasoline:
    Enter this code in the field below: 4667