MA 9601-LR021219FROM
FRX NO, :
,Saxpple ~ackl'low Ppavont{6n A~,'s~nb_~ q~e~ oqd_.iM~h~ten~n~._~J~--°~~
Tho ~o~lo~g fol~ ~n~ ~ ~m~le~ for ~ch ~embly t~t~- A slg~ an6 d~t~ o~gh~ must ~,
submitted to the ])~tdc[ for ~k~ping pu~:
BAc~w P~E~tNTION ~$E~BLY ~ST ~D ~NTEN~OE ~EPORT
The bac)dlow preveat/on ~emb)y de~l~ ~low h~ ~n t~Le6 end mann.ii,ed as r~uired by
Commission m~datbns and is ce~[fi~ to ~ o~rating ~thin *ccepmbl~ parame~m.
TY'PE OF ASSEivfBLY
))oub)e Check Valve
[] Pro-qsu~'e Vaauum Braaker
U Atmosphera Vacuum Breaker
Size ~
DC-CIo:~d
Tight t:l Clo~'~ T/iht
D d mc O",e- rD J~.akk~6
Phe above ik cert{fied to be [rue,
24808,02