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Dispenser Conversion Evaluation Form <br /> Distributor: Sales Person: P.O. # <br /> No r ®U X19 <br /> Existing Dispenser <br /> RE <br /> EIVED <br /> MANUFACTURER /G0.9w� <br /> 16 2015 <br /> SPECIFIC MODEL NUMBER i✓�� � <br /> nFPARTAAFNT <br /> NEW Dispenser <br /> MANUFACTURER 4/L <br /> SPECIFIC MODEL NUMBER ✓ <br /> ExistingSump UDC DISPENSER/ HYDRAULIC CABINET <br /> i , <br /> Is it a Bravo UDC? 09 or Make/Model <br /> Shallow pan or Deep Sump? JA-L4-®w p <br /> n 3 <br /> Water splash lip opening (LD.): Length �4 Width <br /> #of existing Anchor Bolts for concrete pad/island: `Z- <br /> Does the existing UDC have a water splash lip? S <br /> THE FOLLOWING APPLIES TO THE STATE OF CALIFORNIA ONLY <br /> Does conduit exist within 2" of the inner opening? Na ( IF YES, IMAGES ARE REQUIRED) <br /> sus <br /> 2 Does conduit exist outside of the UDC water splash lip? 1V0 (IF YES, IMAGES ARE REQUIRED ) <br /> %_J <br /> FOR ASSISTANCE, CALL 800-AT-BRAVO <br /> FAX TO 323-888-4123 OR EMAIL TO YOUR SALES REPRESENTATIVE <br /> 12A <br /> WNW.SBRAVO.COM made Certified <br /> � � <br /> �� V, <br /> PROBLEM SOLVEO 800-AT-BRAVO in � k�'s Iuimss Eat <br /> MEMBER <br />