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2016 <br />WASHINGTON STATE DEPARTMENT OF HEALTH <br />OFFICE OF IMMUNIZATION AND CHILD PROFILE <br />Organization Name: KITTITAS VALLEY HEALTHCARE <br />Clinic/Facility Name: KITTITAS COUNTY PUBLIC HEALTH <br />PIN: 163000 <br />FROZEN VACCINE PROVIDER <br />RECERTIFICATION FORM <br />Can freezer maintain an average temperature between 5F (-15C) and -58F (-50C)?: 9 yes <br />or O no <br />Does freezer have a separate, insulated door: 0 yes or O no <br />What type of temperature measuring device is used in freezer? <br />Freezer 1: Stand Alone Freezer - Digital Data Logger <br />Freezer 2: <br />Freezer 3: <br />Freezer 4: <br />Freezer 5: <br />Freezer 6: <br />Freezer 7: <br />Freezer 8: <br />0 By signing this document I certify that appropriate storage is in place for frozen <br />Full name of Provider with prescriptive authority*: MARK LARSON <br />Date: <br />