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["用紙-B44-6(13-04-01)"]
["用紙-721-01 (13-04-01)"]
["計量証明等検査依頼書"]
["　　年　　月　　日"]
["一般社団法人　",{"$nulls":4},"≪依頼者≫","住所　〒(　　　−　　　　)"]
["長野県薬剤師会 会長 様",{"$nulls":4},"（結果書掲載名)"]
["次の内容の検査を依頼します。",{"$nulls":5},"氏名：　　　　　　　　　　　　　　　　　　　　　"]
[{"$nulls":6},"TEL：　　　　　　　　　　　　　　　　　　　　　 "]
["受付番号：",{"$nulls":4},"≪結果書送付先≫","住所　〒(　　　−　　　　)"]
[{"$nulls":6},"　　　　　　　　　　　　　　　　　　　　　　　　"]
[{"$nulls":6},"氏名：　　　　　　　　　　　　　　　　　　　　　"]
[{"$nulls":6},"TEL：　　　　　　　　　　　　　　　　　　　　　 "]
["環境計量証明書・検査結果書",{"$nulls":4},"≪請求書≫","宛名：　　　　　　　　　　　　　　　　　　　　  "]
[]
["試料情報","試料種別",null,"　事業所排水・浄化槽放流水・河川水・土壌・底質・汚泥"]
[null,null,null,"　産業廃棄物・肥料・食品・大気・その他(　　　　　　　　　　　　　　　　　　　　)"]
[null,"採取者",null,"氏名：","所属：",null,null,"採取日","年　　月　　日"]
["検　査　項　目","検査内容",null,"　　成分分析・溶出試験"]
[null,null,"・pH",null,"・BOD","・COD","・SS","・DO",null,"・TOC"]
[null,null,"・大腸菌群数(MPN)",null,null,"・溶解性全リン","・全窒素",null,"・全リン"]
[]
[]
[]
["受付番号",null,null,"容器番号","試料名（採取場所・識別名称など）",null,null,"天候","気温(℃)","水温(℃)"]
{"$rows_empty":10}
["備　考　欄"]
[]
[]
[]
["検査料",null,"未請求・請求済・領収済",null,null,"請求額",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"]