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I CONVERSION OR F;z FORM <br />REQUIRED INFORMATION <br />PRINTPLEASE OUT THE SECTIONS BELOW <br />SALES PERSON: P.O. <br />I <br />DISTRIBUTOR: <br />EXISTING/131-D DISPENSER <br />MANUFACTURER <br />SERIES / MAKE <br />MODEL NUMBER <br />THIS INFORMATION IS NEEDED TO DETERMINE NUMBER OF OFFSETS, IF ANY <br />❑ BRAVO BOX? OR MANUFACTURER <br />SHALLOW PAN OR DEEP SUMP <br />WATER SPLASH OPENING: LENGTH WIDTH <br /># OF ANCHOR BOLTS: LENGTH WIDTH <br />DOES THE LDDC HAVE A WATERBPLABH LOP? ❑ YES ❑ NO <br />THIS INFORMATION DEFINES THE UDC SUMP OPENING AND DETERMINES FRAME DIMENSIONS <br />NEWREPLACEMENT DISPENSER <br />MANUFACTURER <br />SERIES / MAKE <br />MODEL NUMBER <br />THIS INFORMATION CONFIRMS COMPLETE PIPING OFFSET PROFILE, DISPENSER -SPECIFIC <br />WATER SPLASH RUNOFF PROFILE, AND ACCURATE ANCHOR POINT LOCATIONS <br />PHONE: 323-888-4133 FAX: 323-888-4123 <br />S. BRAVO SYSTEMS, INC • 2929 Vail Avenue • Commerce • CA • 90040 J I 1 <br />Fax: 323/888-4123 • E-mail: info@sbravo.com • www.sbravo.com Conv-a2000 Order Porm <br />