ORIGINAL
SENDER
COMPLETE THIS SECTION
•
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:
12/16/04
B.M~,,,/
PCB 2004—224
Thomas
C. Safley
Hodge
Dwyer
Zeman
3150 Roland
Avenue
P.O.
box
5776
Springfield,
IL
62705—5776
RECE~VED
CLERK’S OFFICE
DEC
29
2004
STATE OF ILLINOIS
PoIIut~on
Contro’ Boarc~
A
Sign
ture
)~4~J~
~Q
B.
Received by
(
P,i,I’tJl
Name)
bg...~.cJc~\
~ent
0
Addressee
Date of Delivery
/3~
D.
Is delive~/
a&le~
diffentftgy~i
tern 1?
0
Yes
/
If
YES~.enteSeliv
r~s
below:
0
No
~
~):)
(~)....
3.
Service
~~Oertified
Mail
0
Express Mail
0
Registered
0
Return Receipt for Merchandise
0
Insured Mail
0
C.O.D.
4.
Restricted
Delivery?
(Extra
Fee)
0
Yes
2.
Article Number
(rransfer from service label)
7004
0750
0004
3960
2175
PS Form
3811,
February 2004
Domestic Return
Receipt
102595-02-M-1540
I
~
a
Complete items
1, 2,
and 3. Also complete
item
4 if Restricted Delivery
IS desired.
a
Print your name and address on the reverse
so that we can
return the card to you.
a
Attach this card to the back of the mailpiece,
~eAddressedto:12/~04~
PCB
2004-~224
heritage
PS,
Inc.
-
1381
S.
Cre5Cetti~0~~~
Oilman,
IL
60938
0
Agent
A
Signat
O
Addressee
address differ
m
item 1?
eS
ter delivery address belOW
i3~Y
~3cj
Type
fied Mail
C Express
Mail
C
Registered
0
Return
Receipt for Merchandi5e
0
Insured Mail
0
0.0.0.
4.
Restricted
Delivery? (Extra Fee)
Q
Yes
2.
(flansferfrOm~i~Iab~
7004
0750
For
3811,F~’~’2°
Receipt
1o2s95~O2M4540
