SERVICE CALL REQUEST FORM
Name
*
First Name
Last Name
PO #
Phone Number
*
-
Area Code
Phone Number
E-mail
*
Confirmation of receipt will be sent to you via e-mail.
Station Name
*
Station Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
REGISTER ISSUES
Which Register Is Having An Issue?
Please Select
Register #1
Register #2
Register #3
Register #4
Multiple Registers
List Multiple Registers (separate by a space or comma.)
Problem Reported
Please Select
Display/Touchscreen
Terminal Freezing
Pin Pad
Customer Display
Printer
Scanner
Other
Additional Details If Applicable (i.e. error codes, etc.)
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Upload a File
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DISPENSER ISSUES
Pumps Needing Troubleshooting?
Please Select
All Pumps
Multiple Dispensers
#1
#2
#1/2
#3
#4
#3/4
#5
#6
#5/6
#7
#8
#7/8
#9
#10
#9/10
#11
#12
#11/12
#13
#14
#13/14
#15
#16
#15/16
#17
#18
#17/18
#19
#20
#19/20
#20
#21
#20/21
#22
#23
#22/23
#24
#25
#24/25
List Multiple Pumps (separate with space or comma)
Problem Reported
Please Select
Card Reader
Display
Drive off
Fuel Leak
Nozzle-Auto Shut Off
Slow Flow
Other
Issues With Card Reader Appears To Be:
Will not read cards
Keypad is not working
Stuck Debris/Card cannot slide
Other (please specify below)
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Parts Left On Site?
Yes
Yes, but damaged.
No
Location Of Leak
Flow Rate Of Leak
Dripping
Light
Heavy
Still leaking after pump is powered off
Leaking On Which Grade?
87
89
91
Diesel
DEF
Unknown
Which Grade Is Experiencing Slow Flow?
87
89
91
Diesel
DEF
Multiple Grades (if chosen, specify below)
Additional Details If Applicable (i.e. error codes, etc.)
Report Another Dispenser Issue
Yes
No
Pumps Needing Troubleshooting
Please Select
All Pumps
Multiple Dispensers
#1
#2
#1/2
#3
#4
#3/4
#5
#6
#5/6
#7
#8
#7/8
#9
#10
#9/10
#11
#12
#11/12
#13
#14
#13/14
#15
#16
#15/16
#17
#18
#17/18
#19
#20
#19/20
#20
#21
#20/21
#22
#23
#22/23
#24
#25
#24/25
List Multiple Pumps (separate with space or comma)
Problem Reporting
Please Select
Card Reader
Display
Drive off
Fuel Leak
Nozzle-Auto Shut Off
Slow Flow
Other
Card Reader Issues Appear To Be:
Will not read cards
Keypad is not working
Stuck Debris/Card cannot slide
Other (please specify below)
Picture Upload
Upload a File
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Location of Leak
Flow Rate of Leak
Dripping
Light
Heavy
Still leaking after pump is powered off
Parts Left On Site?
Yes
Yes, but damaged.
No
Leaking on which grade?
87
89
91
Diesel
DEF
Unknown
Which grade is experiencing slow flow?
87
89
91
Diesel
DEF
Multiple Grades (if chosen, specify below)
Rate of Slow Flow
Slow (under 3-5 gallons per min)
Extreme Slow Flow (under 2 gallons per min)
Any other details you would like to add regarding your service request?
VEEDER ROOT ALARMS
Alarm Type
Other
Fill
STP (4hr)
Annular
Dispenser Pan/UDC(4hr)
Showing H20
List Alarm As Shown
Another Alarm Is Reporting
Yes
No
List Alarm Specifics
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STATE AGENCY WRITE UP
My Site Was Inspected By
Southern Nevada Health District (SNHD)
Weights & Measures (W & M)
Air Quality
Fire Marshall
Nev. Department of Environmental Protection (NDEP)
Other
A copy of the write up will be sent
Via Facsimile, 1-702-736-8372
Via E-Mail, dispatch@ideconv.com
Upload My Write Up
Upload a File
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Send Me A Copy Of The Completed Documentation
Yes
No
E-mail
Upload Photo
Upload a File
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Additional Details
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SUBMIT
Any Other Information that would help us service you better?
SUBMIT
Should be Empty: