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Below Cost Gas Pricing Complaint Form
Date
Complainant Information			Violator Information
Name			Name
Address			Address
City, State, Zip			City, State, Zip
Phone			Phone
Source Terminal			Source Terminal
Date of Last Load			Date of Last Load
Pump/Street Price			Pump/Street Price
87 octane	Mid-grade	Premium	87 octane	Mid-grade	Premium
Allowable Retail Price			Allowable Retail Price
87 octane	Mid-grade	Premium	87 octane	Mid-grade	Premium
For office use only
Complaint Number		Business ID	Date Received
Disposition
Authorized by:			Date Closed
Return forms to:	MN Department of Commerce Weights and Measures Division 2277 Highway 36 Roseville, MN 55113		Contact:	MN Department of Commerce Weights and Measures Division Phone: 651-639-4010 Fax: 952-435-4040