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Dispenser Conversion Evaluation Form <br />Distributor: Sales Person: P.O. # <br />Existing Dispenser <br />MANUFACTURER <br />SPECIFIC MODEL NUMBER <br />e5e91 NEW <br />Dispenser <br />SPECIFIC MOF)EL NUMBER <br />Existing UDC Sump DISPENSER / HYDRAULIC CABINET <br />LENGTH '� <br />Is it a Bravo UDC? El or Make/Model <br />Shallow pan or Deep Sump? <br />Water splash lip opening (I.D.): Length 2 Width WATER SPLASH LIP <br /># of existing Anchor Bolts for concrete pad / island. <br />Does the existing UDC have a water splash lip? <br />THE FOLLOWING APPLIES TO THE STATE OF CALIFORNIA ONLY <br />Does conduit exist within 2" of the inner opening? <br />— <br />(IF YES, IMAGES ARE REQUIRED) <br />121 Does conduit exist outside of the UDC water splash lip? (IF YES, IMAGES ARE REQUIRED ) <br />`, <br />FOR ASSISTANCE, CALL 800 -AT -BRAVO <br />FAX TO 323-888-4123 OR EMAIL TO YOUR SALES REPRESENTATIVE <br />:.., .. 12A <br />•P WWW.sBRAVO.COM ,> made Mj <br />PR06LEMSOLVE❑ SOA -AT -BRAVO 4"°""' art USAM E M B E R <br />