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    Weights and Measures

    Complaint's First Name:    
    Complaint's Last Name: 
    Address:  
    City:     State:     Zip:  
    E-Mail Address: 
    Daytime Phone #:         Evening Phone #:  
     
    Date of Incident:  
    Business Name:  
    Business Address: 
    Business City:  
    Device (gas pump, scale, advertisement, package):
    Location of Device:
    Pump number (if applicable):  
    What happened? 
     
    Comments: