•
    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:
    4/7/05
    AC
    2005—055
    Harold Bruley
    850(West Jackson
    Virden,
    IL 62690
    RECE~VED
    CLERK’S OFFICE
    APR
    182805
    STATE OF ILLINOIS
    Pollution
    Control Board
    ~,
    ~7~e/
    0
    Agent
    J1~
    Ii
    0
    Addressee
    ~,,~eceived
    by
    (Printed Name)
    9ate~of
    Delivery
    ~
    D.
    Is
    delivery address different from
    item 1?
    0
    Yes
    If YES, enterdelivery address below:
    0
    No
    3.
    Service Type
    ~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
    if
    SENDER:
    COMPLETE THIS SECTION
    COMPLETE THIS SECTION ON DELIVERY
    A.
    Signature
    x~-~,I
    B.M./~
    2.
    Article Number
    -
    (rransfer from service label)
    7004
    2890
    0004
    2296
    4588
    PS Form
    3811,
    February 2004
    Domestic Return
    Receipt
    10259s-02-M-1540

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