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BRAVO <br /> Conversionr • Form <br /> DISTRIBUTOR: PME P O_#: <br /> SALESPERSON: DICK KIENE DATE: 01 / 13 /2017 <br /> I I OL[call 11114M I]AA r <br /> Yes No <br /> lis it a Bravo UDC? F-10 R a <br /> IF NOT A BRAVO UDC WESTERN FIBERGLASS <br /> MAKE/MODEL# <br /> SHALLOW PAN DEEP SUMP F,7/ QUANTITY 1 <br /> WATER SPLASH LIP OPENING (I.D.) <br /> LENGTH: 181/2 WIDTH: 10-1/2" <br /> NUMBER OF EXISTING ANCHOR BOLTS FOR CONCRETE PADASLAND: 2❑ <br /> Yes No <br /> 'DOES THE EXISTING UDC HAVE A WATER SPLASH UP? ❑ <br /> EXISTING DISPENSER <br /> NEW DISPENSER rr <br /> DISPENSER BENNETT DISPENSER WAYNE <br /> MANUFACTURER: MANUFACTURER: <br /> DISPENSER 3924 DISPENSER G6202D <br /> MODEL #: MODEL #: <br /> FOR THE STATE OF CALIFORNIA - PURCHASE OF ADDITIONAL COMPONENTS MAY BE REQUIRED <br /> Does conduit exist within 2" of the inner opening? ❑ (IF YES: Retrofit plates required in <br /> California. Retrofit plates recommended <br /> Yes No outside of California.) <br /> "Does conduit exist outside the UDC water splash lip?❑ Fv/1 IF YES, CHECK BOX 2 BELOW <br /> Is conduit on 1 or 2 © 1 SIDE 1:1 <br /> 2 SIDES AND WIDE FRAME DISPENSERS <br /> sides of vapor panel? <br /> *STANDARD CONVERSION FRAME WILL NOT WORK.....CONTACT FACTOR' <br /> FOR ASSISTANCE, CALL_ Boa-AT-BRAVO <br /> FAX TO 323-888-4123 OR EMAIL TO YOUR SALES REPRESENTATIVE <br />