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BRAVO <br /> DispenserVww) • •n Evaluation Form <br /> DISTRIBUTOR: Northwest Pump & Equipment P.O.#• <br /> SALESPERSON: Art Gomez DATE: <br /> EXISTING DISPENSERR NEW DISPENSER R <br /> DISPENSER DISPENSER <br /> MANUFACTURER: MANUFACTURER: <br /> DISPENSER DISPENSER RECEIVED <br /> MODEL: MODEL: <br /> DEC 0 5 2017 <br /> r,,-'NN'lRo)NNIFN-IA , 1II•AI,'I'lI <br /> • BSI•;I':UZ Fel h;IN.l. <br /> DISPENSER! HYDRAULIC CABINET <br /> Is it a Bravo UDC?Fl or Make/Model LENGTH t= <br /> Shallow pan or Deep Sump? <br /> Water splash lip opening (LD.): Length Width o <br /> #of existing Anchor Bolts for concrete pad/island: 3 WATER SPLASH LIP <br /> FOR THE STATE OF CALIFORNIA - PURCHASE OF ADDITIONAL COMPONENTS MAY BE REQUIRED <br /> 111 <br /> Does conduit exist within 2"of the inner opening? Y/N IF YES:Retrofit plates required in <br /> California.Retrofit plates recommended <br /> outside of California. <br /> :2: Does conduit exist outside of the UDC water splash lip? Y/N IF YES:Check one of the boxes <br /> below. <br /> Is conduit on 1 or 2 ❑ 1 SIDE ❑ * 2 SIDES AND A WIDE FRAME DISPENSER <br /> sides of vapor panel? <br /> *STANDARD CONVERSION FRAME WILL NOT WORK.....CONTACT FACTORY <br /> FOR ASSISTANCE, CALL 800-AT-BRAVO <br /> FAX TO 323-888-4123 OR EMAIL TO YOUR SALES REPRESENTATIVE <br />