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T SocZa 'st ve 4 '81,7E.3` ZL4q& I�w k6Ar� Alij Lp*jw', Lob, cA- q =4iz. <br />Dispenser Conversion Evaluation Form <br />Distributor: ' <br />Sales Person: <br />P.O. # <br />Existing -Dispenser No <br />MANUFACTURER C-st ILBA21.O ENVIR&NI <br />SPECIFIC MODEL NUMBER DEI <br />NEW Dispenser <br />MANUFACTURER Gil-1ZkW,0 <br />SPECIFIC MODEL NUMBER _lex—S <br />24 2014 <br />ENTAL HEALTH <br />ATMENT <br />Existing UDC Sump 1k DISPENSER I HYDRAULIC CABINET <br />F��//WATER <br />TH <br />Is it a Bravo UDC? � or Make/Model <br />Shallow pan or Deep Sump? <br />Water splash lip opening (I.D.): Length_Ltg Width�O" SPLASH LIP <br /># of existing Anchor Bolts for concrete pad / island: <br />Does the existing UDC have a water splash lip? 8 ss <br />FOR THE STATE OF CALIFORNIA - PURCHASE OF ADDITIONAL COMPONENTS MAY HE REQUIRED <br />Does conduit exist within I" of the inner opening? (IF YES, IMAGES ARE REQUIRED) <br />;� Does cdnduit exist outside of the UDC water splash lip? (IF YES, IMAGES ARE REQUIRED ) <br />I--2-' <br />FOR ASSISTANCE, CALL 800 -AT -BRAVO <br />FAX TO 323-888-4123 OR EMAIL TO YOUR SALES REPRESENTATIVE <br />14A <br />,•)0Q B PAV0 W/WW./S� BRAVO.COM dgmade�N,��1 <br />PLi(]BI.EM SOLVED 800 -AT -BRAVO SA MLMBE K <br />