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Dispenser Conversion Evaluation Form <br />Distributor: Sales Person: R.O. # <br />Existing Disperaser <br />MANUFACTURER 6—�"1 v je C - y <br />SPECIFIC MODEL NUMBERS C�C-;- i1 "7 <br />MANUFACTURER I I-V <br />SPECIFIC MODEL NUMBER'_ 15 f.� �� t e �' ISX31,`f <br />Is it a Bravo UDC? <br />or Make/Model <br />Shallow pan or Deep Sump? !h a /f OL", <br />Gj ! f <br />LENGTH <br />Water splash lip opening (I.D-): Length Width�� wnrEe saiasH cis <br /># of existing Anchor Bolts for concrete pad 1 island: <br />Does the existing UDC have a water splash lip? <br />Dees conduit exist within 2" of the inner opening? 5 (IF YES, IMAGES ARE REQUIRED) <br />:2;�` �Does conduit exist outside of the UDC water splash lip? '0 (IF YES, IMAGES ARE REQUIRED) <br />ri M# • # [' <br />4 <br />FAX TO 323-888-4123 OR EMAIL TO YOUR SALES REPRESENTATIVE <br />12A <br />OQ <br />B RAV 0WWW.SBRAV'O.COM &GL made <br />WMWtrac�ea�r800-AT-BRAVO q <br />nnsc��ve rrrrw �tl L�S!`i s�� ,n..— <br />