2. Customer Name*
4. Street, City, State, Zip*
6. Best Daytime Telephone Number with Area Code*
7. Email Address
9. Do you wish to be contacted once complaint is investigated and/or investigation is complete?

   1. Yes
   2. No
10. If answered yes, please check the method we should use to contact you

    1. Telephone
    2. Email
12. Business Complaint / Concern:
14. Business Name*
16. Street, City, State, Zip*
18. City, Borough, Township
20. Telephone Number with Area Code
22. What type of complaint?*

    1. Gasoline
    2. Scale
    3. Price Verification / Scanning Device (PLU & UPC)
    4. Parking Meter
    5. Other
24. Pump Number*
26. Grade*

    1. Regular
    2. Premium
    3. Super
    4. Diesel
    5. Kerosene
    6. Other
28. Department*

    1. Meat
    2. Seafood
    3. Deli
    4. Bakery
    5. Jewelry
    6. LPG
    7. Register Number
    8. Other
30. Type
32. Register Number
34. Products not correct
36. Pole Number
38. Serial Number
40. Lot Number
42. Meter Number
44. Price Charged
46. Price Advertised
48. Time Given
50. Time Advertised
52. Do you have a receipt?

    1. Yes
    2. No
54. My complaint/concern is as follows:*
56. Signature
    Submission of this form serves as permission given to the Westmoreland County Weights and Measures Inspectors to act on my behalf.
Leave This Blank:


58. 1. Receive an email copy of this form.
59. Email address

    This field is not part of the form submission.

60. Submit

* indicates a required field