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[{"$nulls":4},"保管場所使用権原疎明書面（自認書）"]
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["　　証明申請・届出　に係る保管場所である　土地・建物　は、私（当法人）の所有であることに間違いありません。"]
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[{"$nulls":3},"　警察署長　殿"]
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[{"$nulls":10},"年",null,"月",null,"日"]
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[{"$nulls":7}," 〒（　　　―　　　　）"]
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[{"$nulls":7},"住　所"]
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[{"$nulls":8},"電　話"]
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[{"$nulls":7},"氏　名"]
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["　備考","１　保管場所証明申請の場合は証明申請に、保管場所届出の場合は届出に〇を付けてください。"]
[null,"２　土地・建物については、どちらか当てはまる方（両方に当てはまる場合は両方）に〇を付けてください。"]