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[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"※黄色の部分は必ずご記入ください。"]
[null,null,null,"提出用",null,null,null,null,null,null,null,null,null,null,null,null,null,"簡易専用水道検査依頼書(現場検査）"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"受付年月日　　　　　　年　　　月　　　日"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"受 付 番 号　　　K"]
[]
[]
[null,null,null,"　水道法(昭和32年法律第177号）第34条の2第2項の規定に基づく検査を次のとおり依頼します。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"検査をご依頼される皆様へ"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"検査結果が特に衛生上問題があると認められた場合、管轄する市町または保健所に、当協会がその旨を代行報告することについて同意いただけますか。\n\n"]
[null,"＊印字事項は前回通りとなっております。変更の場合は二重線で取消し、正式なものを余白に記入して下さい。(訂正印必要)"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"〒"]
[null,null,null,"簡易専用水道",null,null,null,null,null,null,null,null,null,null,null,"住所："]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"はい",null,null,null,null,null,"いいえ"]
[null,null,null,"設置者住所氏名"]
[]
[null,null,null,"(法人の場合は事務所所在地および名称ならびに代表者氏名）",null,null,null,null,null,null,null,null,null,null,null,"＊役職名および代表者氏名をご記入ください。（例：理事長　　○○　太郎）"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"個人所有者の方へ"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"検査を受検された旨を、管轄する市町または保健所に、当協会が情報提供することについて同意いただけますか。"]
[]
[null,null,null,"簡易専用水道の　　　\n所在地及び当該　　　　\n建築物の名称"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"〒"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"はい",null,null,null,null,null,"いいえ"]
[]
[]
[null,null,null,"建築物の用途",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"竣工年月",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"施設数"]
[]
[]
[null,null,null,"施設の概況",null,"給水方式",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"防錆剤",null,null,null,null,null,null,null,null,null,null,null,"滅菌装置使用",null,null,null,null,null,null,null,null,null,null,null,"利用者数",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"使用水量"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"人/(日）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"ｍ3/月"]
[]
[null,null,null,null,null,"水槽の種別",null,null,null,null,null,null,null,null,"有効容量",null,null,null,null,null,null,null,null,null,null,null,"槽数",null,null,null,null,null,null,"材質",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"構造型式",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"設置場所"]
[null,null,null,null,null,"受 水 槽"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"ｍ3",null,null,null,null,null,null,"基"]
[]
[null,null,null,null,null,"高置水槽"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"ｍ3",null,null,null,null,null,null,"基"]
[]
[null,null,null,"検査実施についての\n\n連　　絡　　先"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"所属",null,null,null,null,null,null,null,null,null,null,null,"設置者",null,null,null,null,null,null,null,null,null,null,null,null,"部署",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"氏名"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"(いずれかにﾁｪｯｸ）",null,null,null,null,null,null,null,null,null,null,null,"施設駐在者"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"代行者",null,null,null,null,null,null,null,null,null,null,null,null,"TEL",null,null,null,null,null,null,null,null,"-",null,null,null,null,null,null,"-",null,null,null,null,null,null,null,null,null,null,"内線（",null,null,null,null,null,null,null,null,null,null,"）"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"＊管理人の駐在日時（曜日）及びご都合の悪い日時（曜日）をご記入ください。"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"    駐在日：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"   都合の悪い日："]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"＊簡易専用水道検査と同時に水質検査を希望される場合はご相談下さい。"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"＊検査日時は、事前に協議のうえ決定させていただきます。なお，悪天候などにより延期させていただくことがあります。"]
[]
[null,null,null,"そ　　の　　他"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null," （１）建築物における衛生的環境の確保に関する法律に基づく特定建築物に該当の ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"　　有　・　　　無"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null," （２）水槽の検査に脚立が  ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"     必要　・　　　不要"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null," （３）駐車場の  ",null,null,null,null,null,null,null,null,null,"     有　・　    無"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null," （４）検査希望年月",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"年",null,null,null,null,null,"月頃",null,null,null,null,"（検査希望に添えないこともありますのでご了承ください。）"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null," （５）清掃業者名",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," 　清掃(予定)年月日",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"年",null,null,null,null,null,null,"月",null,null,null,null,null,null,null,"日頃"]
[]
[]
[]
[null,null,null,"検査結果書郵送先",null,null,null,null,null,null,null,null,null,null,null,null,null,"設置者",null,null,null,null,null,null,"代行者",null,null,null,null,null,null,"その他",null,null,null,null,null,null,null,"〒"]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"１施設あたり ： 17,500円（税抜）\n別途、消費税相当額を請求させていただきます。"]
[null,null,null,"支払方法",null,"検査手数料",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"※お振り込み手数料は貴方のご負担でお願いします。"]
[]
[]
[null,null,null,null,null,"当 日 支 払",null,null,null,null,null,null,null,null,"  　検査時　　  窓口　",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"年",null,null,null,"月",null,null,null,"日",null,null,null,null,null,null,null,null,"円受領",null,null,null,"受領者（",null,null,null,null,null,null,null,null,null,null,null,"）","領収先",null,null,null,null,null,"依頼者・"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,"請求書宛名",null,null,null,null,null,null,null,null,null,null,null,"設置者",null,null,null,null,null,null,"代行者",null,null,null,null,null,null,"その他",null,null,null,null,null,null,"〒"]
[null,null,null,null,null,"後日支払請求先"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,"送付先",null,null,null,null,null,null,null,null,null,null,null,"設置者",null,null,null,null,null,null,"代行者",null,null,null,null,null,null,"その他",null,null,null,null,null,null,"〒"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"整理者名・月日"]
[null,null,null,"依頼代行者",null,null,null,null,null,null,null,null,null,null,null,"〒"]
[]
[null,null,null,"住所・氏名"]
[null,null,null,"（必要な場合記入）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"担当者名"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"TEL",null,null,null,null,null,null,"-",null,null,null,null,null,null,"-",null,null,null,null,null,null,null,null,null,null,"内線  （",null,null,null,null,null,null,null,null,null,null,")"]
[null,null,null,"本    　  部",null,null,null,null,"：","〒730－8631　",null,null,null,null,null,null,null,null,"広島市中区広瀬北町９－１　　　　",null,null,null,null,null,null,null,null,null,null,null,null,null,"TEL（082) 293-1514（直通）"]
[null,null,null,"東部支所",null,null,null,null,"：","〒720－0092　",null,null,null,null,null,null,null,null,"福山市山手町５丁目３２－２６　　",null,null,null,null,null,null,null,null,null,null,null,null,null,"TEL（084) 952-0007"]
[null,null,null,"（注）　　１　　　天候によっては、連絡のうえ延期させていただくことがあります。"]
[null,null,null,"（注）　　２　　　簡易専用水道検査と同時に水質検査を希望される場合はご相談ください。"]
[null,null,null,"＊本依頼書に記述された情報は、成績書、業務連絡、事業活動及び提供するサービス以外には使用しません。"]
[]
[]
[null,null,null,"一般財団法人　広島県環境保健協会"]
[null,null,null,null,"本     部",null,null,null,null,"：","〒730－8631広島市中区広瀬北町９－１　　　",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"TEL （082) 232-6487(直通）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"FAX （082） 293-8010"]
[null,null,null,null,"東部支所",null,null,null,null,"：","〒720－0092福山市山手町５丁目３２－２６　",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"TEL （084) 952-0007",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"FAX （084） 952-0009"]
[null,null,null,null,"振込先",null,null,null,null,null,"□郵便01390-4-27561　",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"□もみじ銀行広島支店（普）3914332　"]
[null,null,null,null,null,null,null,null,null,null,"□広島銀行横川支店（普）2082751　  ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"□広島信用金庫横川支店（普）479451  "]
[null,null,null,null,null,null,null,null,null,null,"□三菱UFJ銀行広島支店（普）4572394",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"□三井住友銀行広島支店（普）9408281"]
[null,null,null,null,null,null,null,null,null,null,"□三菱UFJ銀行広島中央支店（普）1098894　　"]
[null,null,null,null,null,"＊本依頼書に記述された情報は、検査結果書、業務連絡、事業活動及び提供する"]
[null,null,null,null,null,null," サービス以外には使用しません。"]
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