Burner Equipment Assessment
Complete this form to evaluate the condition, safety, and operational status of burner equipment.
Equipment Identification
*
Location of Equipment
*
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Inspector's Name
*
First Name
Last Name
Visual Inspection Checklist
*
Rows
Pass
Fail
Burner exterior condition
1
2
Burner mounting secure
3
4
No visible leaks
5
6
Proper labeling present
7
8
Operational Inspection Checklist
*
Rows
Pass
Fail
Ignition system functions correctly
9
10
Flame pattern normal
11
12
Safety shutoff operational
13
14
Burner controls responsive
15
16
Rate the overall condition of the burner equipment
*
1
2
3
4
5
Rate safety and compliance with standards
*
Poor
1
2
3
4
Excellent
5
1 is Poor, 5 is Excellent
Last Maintenance Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Maintenance Performed (describe any recent maintenance)
Recommendations or Additional Comments
Submit Assessment
Should be Empty: