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o SENDER: I also wish to receive the <br /> M :complete items 1 and/or 2 for additional services. following SBrVlCeS(for an <br /> m •Complete items 3,4a,and 4b. <br /> m •Print your name and address on the reverse of this form so that we can return this extra fee): a; <br /> card to you. <br /> d <br /> .card <br /> this form to the front of the mailpiece,or on the back if space does not 1. ❑ Addressee's Address 'Z <br /> > m <br /> permit. <br /> y • <br /> Write'Return Receipt Requested'on the mailpiece below the article number. 2. Restricted DBIIVery N <br /> .S •The Return Receipt will show to whom the article was delivered and the date <br /> Consult postmaster for fee. m <br /> delivered. 0 <br /> 04a.Article Number <br /> v 3.Article Addressed to: <br /> d DEPARTMENT OF TOXIC P 858 359 110 <br /> M SUBSTANCES CONTROL 4b.Service Type m <br /> o PROGRAM DATA MANAGEMENT ❑ Registered Kl Certified <br /> SECTION — HQ 10 ❑ Fxpress Mail ❑ Insured 5 <br /> Lu ATTN: "FOOD EXEMPTION <br /> 12 Return Receipt for Merchandise ❑ COD <br /> o NUTIFICATION" 7.Date of!]slivery <br /> a PO BOX 806 <br /> Z - J4 <br /> 5.Received By: nn Name) $!Add/ a ddress(only t: <br /> W r? o <br /> A 6.Signature:(Addressee or Agent ,�Qp <br /> 0 X <br /> Ps Form 3811, December 1994 14 omestic Return Receipt <br />