•
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:
4/7/05
AC
2005—055
Harold Bruley
850(West Jackson
Virden,
IL 62690
RECE~VED
CLERK’S OFFICE
APR
182805
STATE OF ILLINOIS
Pollution
Control Board
~,
~7~e/
0
Agent
J1~
Ii
0
Addressee
~,,~eceived
by
(Printed Name)
9ate~of
Delivery
~
D.
Is
delivery address different from
item 1?
0
Yes
If YES, enterdelivery address below:
0
No
3.
Service Type
~Certified
MaIl
0
Express
Mail
o
Registered
0
Return
Receiptfor Merchandise
o
Insured
Mail
0
C.O.D.
4.
Restricted
Delivery
? (Extra Fee)
0
yes
if
SENDER:
COMPLETE THIS SECTION
COMPLETE THIS SECTION ON DELIVERY
A.
Signature
x~-~,I
B.M./~
2.
Article Number
-
(rransfer from service label)
7004
2890
0004
2296
4588
PS Form
3811,
February 2004
Domestic Return
Receipt
10259s-02-M-1540