SENDER:

COMPLETE THIS SECTION

COMPLETE THIS SECTION ON DELIVERY

I

•

Complete items

1, 2,

and 3.. Also complete

item 4 if Restricted Delivery

is

desired.

•

Print yourname and address on the reverse

so that we can return the card to you.

a

Attach this card to the backofthe mailpiece,

or on the front if~space

permits.

1.

Article

Addressed to:

9/

2

/

04

B

.

M.

AC

2005—010

.

Lawrence

P.

&

Jacqueline

L..Koch

526

Poplar

Highland,

IL

62249

A

Signature

~

B.

Recel4d by

(PrintedName)

Cate

of Delivery

/

LHi~ltfr~Y

0.

Is deliveryaddress different from

item 1?

0

Yes

-

IfYES,

enter delivery address below~

0

No

3,

StrMce Type

~~ertIfied

Mail

o

Registered

0

Express Mail.

0

Return

Receiptfor

Merchandise

o

Insured

Mai!-

0

COD.

4.

Restricted Deliven/I

(Extra-Fee)

0

Yes

2.

Article Number

I

(rransfer

fromservice label)

7004

1160

0005

4126

.

2625

PS Form

3811,

February 2004

Domestlc Return

Receipt

102595-02-M-1 540

•

RECEFV1ED

CLEAK’S OFFICE

SEP

20

200k

STATE OF ILliNOIS

Poflutlon Control Board

RECE~VED

CLERK’S OFFICE

SEP

2 02004

STATE OF ILLINOIS

POIIUflOn Control Board