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0 0 <br /> Dispenser Conversion Evaluation Form <br /> Distributor: Sales Person: P.O. # <br /> Existing Dispenser M 182015 <br /> ENVI NMENTAL. <br /> MANUFACTURER �/ /L3 �0 gar 1�� <br /> SPECIFIC MODEL NUMBER AtUC 3 ,v® <br /> NEW Dispenser <br /> MANUFACTURER G / L- 3.9-,z <br /> SPECIFIC MODEL NUMBER 500 a ofvcy.,w_ Wrxwzh <br /> Existing UDC Sump DISPENSER/HYDRAULIC CABINET <br /> Is it a Bravo UDC? or Make/Model <br /> Shallow pan or Deep Sump? G1Tt'1-1-c�Jti <br /> Water splash lip opening (I.D.): Length �� 4 � Width La :P/4'1 <br /> #of existing Anchor Bolts for concrete pad/island: Z <br /> Does the existing UDC have a water splash lip? <br /> THE FOLLOWING APPLIES TO THE STATE OF CALIFORNIA ONLY <br /> 0_� /./V <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? A)O ( 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 /> 12A <br /> 0Q <br /> BRkVO W1NW.SBRAVO.COM ._ made Certified 16� WBEN ,. )P ,. <br /> 800-AT BRAVO USA <br /> PROBLEM SOLVED In lCim[ci:r f3usmeas En[ rein M E M B E R <br />