Complaints for Motor Fuel

Please provide all information related to your incident relating to motor fuels, including a complete description.

Incident details

Date of incident:*

Description of incident:*

Gas station pump number:*

Fuel grade:*

If this complaint is skimmer related click here: https://www.tdlr.texas.gov/Skimmers

Incident business name:*

Name of contact at location:

Street address:*

City:*

Your details

Do you want to remain anonymous?

If you check “Yes” to submit your complaint anonymously, then DO NOT complete the bottom portion of this form. By submitting your contact information you will no longer be considered anonymous and your information may be subject to release under the Public Information Act, Chapter 552 of the Texas Government Code.

Yes

Preferred contact method:

First name:

Last name:

Street address:

City:

State:

Email:

Phone:

Attachments

Please attach any supporting documentation you have relating to your incident, including: receipts, invoices, picture, etc.

Attachments (BMP, DOC, DOCX, GIF, JPEG, JPG, PDF, PNG, TIFF, XLS, XLSX)

Drop files here, or browse to attach files

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