•

Comp!ete items

1

2, and

3. Also complete

item 4 if Restricted Delivery is desired.

•

Print your name and address on the revei~e

so that .w~.canreturn the card to you.

•

Attach this card to the back of the mailpiece,

or on the~front

if space permits.

1.

Article

Addressed to:

8/5/04

B

.M.

AC: 2004—018

Luther Coleman

624 W. Logan

Harrisburg, IL 62946

3.

Sp~ice

Type

rtified

Mail

Regi~ter~d

fl. Insured Mail

4.

Restricted Delivery?

(Extra Fee)

0 Yes

RECE~VED

CLERK’S OFFICE

AUG

162004

STATE OF ILLINOIS

Pollution Control

Boarc

A.

Signa

re

X

B.

Received by

(P

nted N

e)

~

of

DØvery

/

D.

Is

delivery

address

different

fmrn

item 1~0

Yes

If YES, enter delivery address below:

0

No

C~

Express Mail

o

Return

Receipt for Merchandis~

o

C.O~D.

2.

Article Number

.

:

.

.

.

.

•

(Transfe?fràmscividelabóly

7002086000049618 4896

• PS Form

3811;

FObitiary

2004

• -

•

Domestic Return

Receipt

102595-02-M-15’