CE 1927 Mary St 2012 ,v1
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� " �CASE ACTION FORM
Investigation# b 7/ 2-- DATE:
NAME: }-
ADDRESS OF VIOLATION /902-? U
Action Taken:
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Compliance: ib
SENDER: COMPL TE THIS SECTION COMPLETE THIS SECTION ON DELIVER' .
• Complete items 1,2,and 3.Also complete A. Signature
item 4 if Restricted Delivery is desired. / I ❑Agenz
• Print your name and address on the reverse X `� �A ❑Addressee
so that we can return the card to you. B. Received by(Printed Name) C. Date of Delivery
• Attach this card to the back of the mailpiece,
or on the front if space permits. x
! D. Is delivery addressdifferent from itempt(,❑' :_ IL
1. Article Addressed to: 1 rc4: If YES,enter detfvery address below: ❑ No
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3. Service Type
❑Certified Mail ❑Express Mail
00 71 11 0 ❑Registered ❑Return Receipt for Merchandise
❑Insured Mail ❑C.O.D.
4. Restricted Delivery?(Extra Fee) ❑Yes
2. Article Number 7011 2000 0002 0346 9900
(Transfer from service label)
PS Form 3811, February 2004 Domestic Return Receipt 102595-02-M-1540