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City: State: Zip:
Gas Station Name:
Gas Station City:
Gas Station County:
Gas Station Location - Cross Streets/Coordinates
Date you witnessed the incident (Price):
Approximate time you witnessed the incident (Price:) am pm
What was the price per gallon that you saw?
Grade of Gasoline? regular premium diesel
Are you willing to testify in court regarding complaint? yes no
Comments: Be specific:
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