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["用紙-B44-1(13-04-01)"]
["用紙-721-01 (13-04-01)"]
["水質検査依頼書"]
["                        　　　 　　　　　　             　　　　　年　　月　　日"]
["一般社団法人",{"$nulls":4},"≪依頼者≫",null,"住所　〒(　　　−　　　　)"]
["長野県薬剤師会 会長 様　　　　　　　    "]
["次の内容の検査を依頼します。"]
[]
["受付番号：",{"$nulls":6},"氏名："]
[{"$nulls":7},"TEL：　"]
[]
["試料情報","供給形態",null,"　　　　　　　　上水道・　　　　　　　　簡易水道・　　　　　　　専用水道"]
[null,null,null,"　飲料水供給施設　・　簡易給水施設　・　水道組合"]
[null,"試料種別",null,"　原水（井水・湧水・表流水・その他[　　　　　　　　　]）",{"$nulls":5},"容器番号"]
[null,null,null,"　浄水"]
["採水時情報","採水場所",{"$nulls":7},"採水日・時刻\n\n　　年　　月　　日\n\n　　　　　時　　分"]
[null,"採水者",null,"氏名：",null,null,"所属："]
[null,"天候",null,null,"気温","水温",null,"残留塩素濃度","電気伝導率",null,"時刻も\nご記入\n下さい"]
[null,"当日：\n前日：",null,null,"℃","℃",null,"mg/L","mS/m\n※測定実施時のみ記入"]
["検　査　項　目",null,"・原水全項目（カビ臭：有・無）",{"$nulls":4},"・健康項目（選択は項目名を記入）"]
[null,null,"・浄水全項目（カビ臭：有・無）"]
[null,null,"・省略項目"]
[null,null,"・消毒副生成物  ・亜硝酸態窒素"]
[null,null,"・シアン　　　　・カビ臭項目"]
[]
["備　考　欄"]
[]
[]
[]
["検査料",null,"未請求・請求済・領収済",null,null,"請求額",null,null,null,"受付担当者","入力確認"]
[]
["結果書発行日："]
["請求書発行番号："]
["※お問合せ先：長野県薬剤師会検査センター"]
["              〒390-0802　長野県松本市旭2-11-20   TEL：0263-32-0276、FAX：0263-36-0665"]