OR1GI~LP~VED
    CLERK’S
    OFFICE
    JAN
    202005
    STATE OF ILLINOIS
    Pollution
    Control Board
    SENDER
    COMPLETE THIS SECTION
    •
    Complete items
    1, 2, and 3.
    Also complete
    item
    4
    if Restricted
    Delivery is desired.
    •
    Print your name
    and address on the
    reverse
    so that we can
    return the card to you.
    •
    Attach this card to the back of the mailpiece,
    or on
    the front if space
    permits.
    1.
    Article Addressed
    to:
    1/6/05
    B.N.
    AC 2004—084
    Dick Brown and Jason Bruce
    101 South Broadway
    D.
    Is
    deII~ry
    address
    different
    from
    item 1?
    0
    Yes
    If YES, enter delivery address below:
    0
    No
    3.
    Sprvice Type
    ..ç~ertifiedMail
    o
    Registered
    o
    Insured Mail
    o
    Express Mail
    o
    Return
    Receipt for Merchandise
    o
    C.O.D.
    A.~na~yre
    p
    B.
    ~ec$i
    d by
    (Printed Name)
    /
    (~
    ~..
    ~
    ee
    C.
    Date of
    Delivery
    ~
    V
    Salem,
    IL 62881
    2.
    Article Number
    (rransferfrom sep/ice
    labeD
    7004
    0750
    0004
    3960
    2274
    4.
    Restricted
    Delivery?
    (Extra
    Fee)
    0
    Yes
    PS Form
    3811,
    February 2004
    Domestic Return Receipt
    102595-02-M-1
    540

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