RECEfl/ED
CLERK’S OFFICE
DEC
13
2004
STATE OF ILLINOIS
Pollution Control Board
OR IG.iNAL
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4.
Restricted
Delivery?
(E~t,~
Fee)
0
Yes
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items
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Restricted Delivery is desired.
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Addressee
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name and address on the reverse
sot~we
can
return the
card
to you.
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to the
back
of the maiIpiece,~
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different frem item
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to:
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2
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N.
If YES,
enter delivery
address
below:
0
No
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61081
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0
ReturnReCeIpt
for
Merchandise
0
Insured Mall
0
C.O.D.
4.
RestrIcted
Delivery?
(Extm Fee)
0
Yes
2.
Article
Number
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102595-02M-1S40
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Return
Receipt
for
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D.C.O.D..