ORIGINgJ

STATE OF ILLINOIS

Pollution Control Board

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,

1.MlcleAddressedto:

or on

the front if space

10/6105

permits.

B.M.

I

AC 2005—029

Charles K. Smith

420 S. Promenade

i~.u~.box473-

Havana, IL 62644

0.

Is

ciellv4address different froWltem 1?,..~t..._

If YES, enter delivery address below:

yt

No

CD—

3.

Service Type

,$certrloci Mall

U

Registered

U

Insured Mall

C Express Mall

Q

Return Receipt for Merchandise

C COD.

2.

ktlcie

Number

(Thansferfromservlcelabel)

7005

1160 0002

2069 3718

~I3fl

o Agent

0

Addressee

4.

Restrtcted Deiwery? (Extu

Fee)

C

Yes

PS Form 3811, February 2004

Domestic

Return Receipt

102595-02-1.1.1540