O~AL

RECE~VEO

CLERKS OFFICE

SEP 15 200k

STATE OF ILLMO~S

pollution ContrOt Board

SENDER:

COMPLETE THIS SECT/ON

• Complete items 1, 2, and 3. Also complete

item 4 if Restricted Delivery is desired.

I 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.

,,~celv~dby

(Printed

~

~

NameT

~D~DeIivery

~

0. fs deli~ery

address

different from item

1?

Yes

1.. ArticleAd~~ssedto:9/2/04 B.M.

If YES, enter delivery address below:

0 No

PCB 2~~041

I~1

Zach~anan

I

Lazy

B~Farni

RR 1, Box 79

Lawrenceville, IL 62439

2. Article Number

(rransferfrom sen/ice label)

7004

1160 0005 4123

1522

3. Service Type

rtified Mail

Regi~tered

0

InsUred M~ll

o Express Mail

0 Return Receiptfor Merchandise

o

C.OD.

4. Restricted Delivery?

(Extra Fee)

0 Yes

PS Form 3811, February 2004

Domestic Return Reeeip~

102595-02-M-1

540