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[null,null,null,"As混合物抽出試験試料調書"]
[]
[{"$nulls":7},"    令和　　 　　年　　 　　月　　 　　日"]
[]
[{"$nulls":7},"市町村名"]
[]
[{"$nulls":7},"監督員名","印"]
[]
[null,"　　　　項         　   目",null,null,"記　　　　載　　　　事　　　　項"]
[null,"　　　　工　　 事　　 名",null,null,"工事"]
[null,"　　　　路　　 線　　 名"]
[null,"　　　　工 事 箇 所 名",null,null,"郡・市",null,"　　　  町・村",null,"地内"]
[null,"　    　国 補   ・  県 単",null,null,"所轄課",null,null,"事業名"]
[null,"設　　　　計　　　　概　　　　要",null," 車道・歩道の別","〔 車  道 〕",null,null,null,"〔 歩  道 〕"]
[null,null,null," 混合物の種類"]
[{"$nulls":4},"（　　　　）","（　　　　）","（　　　　）","（　　　　）","（　　　　）","（　　　　）"]
[null,null,null," 設 計 厚  （㎜）"]
[null,null,null," 舗装面積 （㎡）"]
[null,"現　　　　場　　　　配　　　　合　　　　設　　　　定　　　　値",null," 基準密度（g/cm3）"]
[null,null,null," 設計As量 （％）"]
[null,null,null,"　2.36  ふるい通過率"]
[null,null,null," 0.075 ふるい通過率"]
[null,"コアの採取位置"]
[]
[]
[null,"  完 成 検 査 予 定",null,null,"平成　　 年　　 月　　 日  （ 工期　　 年　　 月　　 日　～　　　月　　 日 ）"]
[null,"請　　　　負　　　　業　　　　者　　　　等",null,"　  請　負　者"]
[null,null,null,"　  施　工　者"]
[null,null,null,"　  合材 工場"]
[]
[null,"注１．",null,"　この調書に、試験コア、基準密度表、及び配合設計書を添えて公的機関 （ (公財)岩手県"]
[null,null,null,"  土木技術振興協会 ）に提出すること。"]
[]
[null,"注２．",null,"　面積 １，０００㎡以上の舗装工事は、当該工事で使用した全ての舗装合材を公的機関 "]
[null,null,null,"　（ (公財)岩手県土木技術振興協会 ）で試験すること。"]