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Maryland Department of Agriculture
Weights and Measures Section
410-841-2765
Complaint Form
Contact information:
*First Name:______________________ Last Name:______________________
Work Phone:______________________ Home Phone: ____________________
E-mail: __________________________________________________________
Name of Business:__________________________________________________
Location of Business: ___________________________________________
Date of Incident:__________________ Time of Incident:_______________
Device Type(scale, gas pump, etc): ____________________________________
Device Identification(gas pump number, etc)___________________________
Describe the Incident: ________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
Do you Have the Receipt? Yes/No
** All information may be released under the Freedom of Information Act.
Complaint may be filed anonymously
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