MALL LOGO

CERTIFICATION

This is to certify that ___________________________________________ BRANCH located at

____________(MALL AND MALL ADDRESS)____________ is being served with a plumbing
connection where its wastewater is conveyed to a centralized Wastewater Treatment Facility
(WWTF) which is operated and maintained by _______________(MALL)_______ Building
Administration.

This certification is issued upon the request of ______(REQUESTOR)______(BRANCH) to

support its application for_______(PURPOSE)_________________________.

Signed:

__________________________ _________________________
[Signature over printed name of [Signature over printed name of
Building Administrator] Mall Manager]
TIN: ______________________ TIN: ______________________

REPUBLIC OF THE PHILIPINES)

QUEZON CITY) S.S

SUBSCRIBED AND SWORN to before me this ________ day of _________, Affiant

personally appeared before me with Residence Certificate No. ______ issued on ______ at
______

IN WITNESS WHEREOF, I have hereunto signed this Certification on the date and place
first above written.

Doc. No. __________

Page No. __________
Book No. _________
Series of 2014