ORiGINAL
CLERK’S OFFICE
JAN
31
2005
STATE OF ILLiNOIS
Pollution
Control Board
SENDER
COMPLETE THIS SECTION
COMPLETE THiS SECTiON ON DELIVERY
Complete Items 1,
2, and 3. Also complete
A.
Signature
item 4 if Restricted Delivery is desired.
0
Agent
U
Print your name and address
on
the reverse
~7\~\ir’~Ci.
L~.Y¼_)t
1t
~Y\O~r
0
Addressee
so that we can return the card to you.
s/Received by
(P
nted
Aiame)
C.
Date of Delivwy
U
Attach this
card to the back of the mailpiece,
‘~“\
i
or on the front if space permits.
~
I~’\~~
ti ~
(
D.
Is delivery address different
fr~ni
item
1?
0
Yes
1.
Article Addressed to:
1
/
20
/
05
B
.
M.
/‘
If YES, enter delivery address~eIow:
0
No
PCB
2005—105
&
PCB
2005—107V
Burroughs
Ag Services,
Inc.
Box 488
Toluca,
IL 61369—9801
3.
Service Type
o
Certified Mail
0
Express Mail
o
Registered
0
Return
Receiptfor Merchandise
o
Insured Mail
0
C.O.D.
4.
Restricted
Delivery?
(Extra Fee)
0
Yes
2.
Article Number
(Transfer from service label)
7004 0750
0004
3960
2540
PS
Form
3811,
February 2004
Domestic Return
Receipt
102595-02-M-1540
SENDER
COMPLETE THIS SECTION
•
Complete
items 1, 2, and
3. Also complete
H
A.
Si
n
ture
item
4
if
Restricted Delivery is desired.
x
—~j
~j
0
Agent
•
Print your name and address
on the reverse
u
~..
0
Addressee
so
that we can
return the card to you.
B
Received by
(Printed
Nam~1’\~
C.
Date of Delivery
•
Attach this
card to the back of the
mailpiece,
or on the front if space permits.
I
1.
Article Addressed
to:
1
/
20
/
05
B. N.
/
D.
Is delivery address different from item 1?
0
Yes
PCB
2005—105
&
PCB
2005107\,/
If
YES,
enterdeliveryaddress below:
0
No
Keith
Honegger
3200
Old Troy Road
Glen
Carbon,
IL
62034
_________________________________
3.
Service Type
o
Certified Mail
0
Express Mail
o
Registered
0
Return Receipt for Merchandise
o
Insured Mail
0
C.O.D.
4.
Restricted
Delivery?
(Extra
Fee)
0
‘~‘~5
2.
Article Number
(Transfer from service
label)
7005
0750
0004
3960
2533~
PS
Form
3811,
February 2004
Domestic Return
Receipt
1O2595-O2~M-154o
