•

itemComplete4 if Restricteditems

1, 2,Deliveryand 3. Alsois

desired.complete

x

A. Signature

(7

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0 Agent

• -Print your name and address on the reverse

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so that we can return the card to you.

B~Received~,y(Printed

Name)

0.. 6ate of Delivery

• Attach this card to the back ofthe mailpiece,

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or on the front ifspace permits.

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D. Is delivery address different’from item 1? 0 ‘~‘es

1~Article Addressed to: 7 /

22

/ 04

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If YES, enter delivery address below:

0 No

AC 2004—087

Herman “Bud” Krohe

5061 N. Hagener Road

Route:.2

.

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Box 16 1A

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0

Exp~ssMaiI

Beards town, IL 62618

0 1~egistered

0 Return Receipt for Merchandise

0

Insured M&1’ .. 0 C.O.D.

4.

Restricted~elivery?‘~‘ExtraFee). ~-‘

0 ~i~s

2 ArtIcle Number

(rransferfromservlcelabe!)

- -

7002 2030 0004: :5523

-

9095:

-.

PS-Form 3811, IFebrualy 2004.

Domestic Return Receipt

102595-02-M-1540

RECE~VED

CLERK’S OFFICE

AUG - 2 2004

STATE OF ILUNOIS

PoIIut~onControl Board