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BRAVO <br /> 13 <br /> DISTRIBUTOR: ,. P.O.#: <br /> LJ <br /> 7R <br /> L !7 <br /> SALESPERSON: DATE: , / <br /> v)0 v 2 <br /> HEALTH <br /> DISPENSER NT NEW DISPENSER <br /> DISPENSER DISPENSER <br /> MANUFACTURER: OZ-,-� Lldltib:r MANUFACTURER:' <br /> DISPENSER U1574- SSI� DISPENSER &-12- - 22W <br /> MODEL:— [MODEL:— <br /> DISPENSER HYDRAULIC CABINET <br /> Is it a Bravo UDC?Fl or Make/Model SGrI�6' I.ENCTFI <br /> Shallow pan or Deep Sump? <br /> Water splash lip opening(I.D.): Length Width <br /> #of existing Anchor Bolts for concrete pad/island: WATER SPLASH LIP <br /> FOR THE STATE DI CALIFORNIA - PURCHASE Q€ ADUFFIDIEAL COMPONENTS Mff BE RERUIRED <br /> Does conduit exist within 2"of the inner opening? Y/N_ �� IF YES:Retrofit plates required in <br /> California Retrofit plates recommended <br /> y 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 pane(? <br /> +$UI 11 <br /> tMAROCONVFASION FRAME WILL NO ORK.r co- CTFFA;T0 Y <br /> FOR ASSISTANCE, CALL 800-AT-BRAVO <br /> FAX TO 323-888-4123 OR EMAIL TO YOUR SALES REPRESENTATIVE <br />