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EQUIPMENT AND FINISH SCHEDULE
Complete this form and submit as part of your plans.
Name of facility:
Location of facility:
Location
Number of Sinks
Supplies
Workstation(s)
#_________
Hand wash sink
#_________
Permanently plumbed, hot and cold running water, containerized
liquid soap, and single-use paper towels from a wall mounted
touchless dispenser.
Restroom(s)
#________
Hand wash sink
#_________
Permanently plumbed, hot and cold running water, containerized
liquid soap, and single-use paper towels from a wall mounted
touchless dispenser.
Decontamination &
Sterilization Room
Bio sink (if sterilizing)
Sterilizing: Y/N
Permanently plumbed, hot and cold running water, containerized
liquid soap, and single-use paper towels from a wall mounted
touchless dispenser.
Decontamination &
Sterilization Room
Hand wash sink
(Recommended)
Permanently plumbed, hot and cold running water, containerized
liquid soap, and single-use paper towels from a wall mounted
touchless dispenser.
Item
Location
Manufacturer
Model Number
Autoclave
(Provide specification
sheets)
Ultrasonic Machine
(Provide
specification sheets)
Tattoo/Perm. Cosmetic Machine
(Provide specification sheets
showing backflow prevention)
Manufacturer
Make and Model
List Disposable Instruments (Tools/Tips/Grips/Tubes)
Water Heater Manufacturer & Model Number
Medical Waste Hauler/Disposal Company
Item Description
Floor Type/Material (Ex. Ceramic Tile)
Wall Finish (Ex. Semi-gloss sheetrock)
Restroom
Procedure Areas
Decontamination & Sterilization Room
Body Piercing Room
Drawing/Stencil Area
Reception and Waiting Area
Item Description
Practitioner Chair
Client Chair
Body Piercing Table
Stool
Arm Rest
Mayo Trays
Counters
Storage Cabinets
Lighting
Other
Rev. 9/2019
Contra Costa County Environmental Health, 2120 Diamond Blvd, Suite 100, Concord, CA 94520
Phone: (925) 608-5500 or Fax: (925) 608-5502 Website: www.cchealth.org/eh/
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Completed 10 January 2021

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