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["様式第44（81条関係）"]
[null,null,null," × 整理番号"]
[null,null,null," × 審査結果"]
[null,null,null," × 受理年月日","年   月   日"]
[null,null,null," × 検査番号"]
[]
["充 て ん 設 備 保 安 検 査 申 請 書"]
[]
[null,null,null,"           　　     年    月    日"]
[]
["指定保安検査機関"]
["　株式会社 ガ ス 檢 　殿"]
[]
[null,null,"氏名又は名称及び法人に"]
[null,null,"あってはその代表者の氏名",null,"㊞"]
[null,null,"法人にあってはその法人番号"]
[null,null,"住   所"]
[]
[]
["    液化石油ガスの保安の確保及び取引の適正化に関する法律第37条の6第1項本文の"]
["  検査を受けたいので、次のとおり申請します。"]
["  "]
["  1 充てん設備の使用の本拠の名称及び所在地"]
[]
["  "]
["  "]
["  "]
["  2 充てん設備の許可の年月日及び許可番号"]
[]
["  "]
["  "]
["  "]
["  3 前回の保安検査の検査年月日（保安検査を受けたことのない充てん設備にあっては、"]
["　　完成検査の年月日）及び充てん設備保安検査証の検査番号"]
[]
["  "]
["  "]
["≪参考≫"]
["事業所連絡担当者","所属                  TEL"]
[null,"氏名"]
["保安検査実施予定日","　　      年      月      日"]