Certificate of Interconnection TEMPLATE

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Company Heading

Date

Name of EMB Regional Director


Regional Director, EMB Region # ______
Address

Subject: CERTIFICATION OF INTERCONNECTION

Dear Director _______________:

Warm Greetings!

This is to certify that ______________________(Name of


Company/Establishment/Lessee) is a tenant/lessee of ______________________(Name of
Building) operated by _________________(Name of Company/Lessor)

This further certifies that _______________ ______________________(Name of


Company/Establishment/Lessee) is connected to the building drainage and will be discharging
their wastewater effluent into the ________________(Choose one - Septic Tank or Wastewater
Treatment Facility) owned/maintained by _________________ (Name of Company/Lessor).

This certification is being issued to _____________(Name of PCO) as one of the


requirements for the application of Wastewater Discharge Permit to DENR-Environmental
Management Bureau Regional Office.

We trust that this Certificate fulfills the requirements of DENR-EMB Regional Office.

Sincerely,

(Signature Over Printed Name)


Position
Date signed_________________

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