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's —r, 521 dot Wss-5- VXTVLok t"p tx"y itf Lo b% c3�. <br />`3SL24fo <br />Dispenser Conversion Evaluation Form <br />Distributor: Sales Person: P.O. # <br />Existing Dispenser NOV 2 2014 <br />MANUFACTURER Q ILSPaCo ENVIRONME AL HEALTH <br />P�1I EENT <br />SPECIFIC MODEL NUMBER F—"C40M - <br />MANUFACTURER G1LQt'ZC0 <br />SPECIFIC MODEL NUMBER -100-S 63�� <br />Existing UDC Sump <br />Is it a Bravo UDC? d or Make/Model IL <br />Shallow pan or Deep Sump? <br />Water splash lip opening (I.D.): Length -r --41Z'--- Width -7-0" <br /># of existing Anchor Bolts for concrete pad / island: <br />Does the existing UDC have a water splash lip? b F—$ <br />DISPENSER / HYDRAULIC CABINET <br />LENGTH�� <br />I <br />11, 21 <br />�O <br />3 WATER SPLASH LIP <br />FOR THE STATE OF CALIFORNIA - PURCHASE OF ADOITIDNAL COMPONENTS MAY RE REQUIRED <br />1 Does conduit exist within 2" of the inner opening? ( IF YES, IMAGES, -ARE REQUIRED ) <br />2 Does conduit exist outside of the UDC water splash lip? (IF YES, IMAGES ARE REQUIRED) <br />FOR ASSISTANCE, CALL 800 -AT -BRAVO <br />FAX TO 323-888-4123 OR EMAIL TO YOUR SALES REPRESENTATIVE <br />14A <br />WWW.SBRAVO.COM —made rW <br />OP*) BRAV4 p vl�P/ <br />PRaBLEMSOLVED 800 -AT -BRAVO ..• in USA ME" a E It <br />