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A <br />■ Complete items 1, 2, and 3. Also complete <br />A. Signatu <,. <br />item 4 if R t ' <br />X ❑ Agent <br />■ Print your Vd--m. n verse <br />❑ Addressee <br />B ived by ( Printed Name) <br />C. Date of Delivery <br />so that We a <br />■ Attach this card to the back of the mailpiece, <br />_ i <br />or on the front if space permits. <br />D. Is delivery ad <br />If YES, ente i <br />i ?( ❑ Yes <br />I I h No <br />1. Article Addressed to: <br />CHEVRON STATION #201383 <br />1960 W 11TH ST <br />TRACY CA 95376 <br />JAN 0 5 2005 <br />SAN lnAQ <br />serviMI)N E�HEALT� DEPT <br />Certified Mail ❑ Express Mai <br />❑ Registered ❑ Return Receipt for Merchandise <br />❑ Insured Mail ❑ C.O.D. <br />4. Restricted Delivery? (Extra Fee) ❑ Yes <br />2. Article Number 7004 2510 0003 3789 1556 <br />(Transfer from service Is <br />fPS Form 3811, February 2004 Domestic Return Receipt <br />0 <br />