Information

JB Pritzker, Governor

James A. Rivera, State Fire Marshal

Division of Petroleum & Chemical Safety

State of Illinois
Employment Opportunities
Ready Illinois
Find us on Facebook

Division of Petroleum & Chemical Safety

Facility Details

Facility Number:	2042023
Status:	Active
Facility Name:	Sam's Club #6339
Address:	5670 NW Hwy Crystal Lake, IL 60014
County:	McHenry
Property Parcel:	19-04-376-012
Facility Type:	Attended Self-Service Station
Owner Type:	Private
Green Tag Decal:	Y002708
Green Tag Issue Date:	5/15/2023
Green Tag Expiration Date:	12/31/2025

Owner Details

Owner Name:	Sam's West, Inc.
Owner Address:	2101 SE Simple Savings Drive Bentonville, AR 727160745
Owner Status:	Current Owner
Purchase Date:
Type of Financial Responsibility:	Commercial Insurance
Financial Responsibility Reporting Due Date:	4/29/2025

Motor Fuel Dispensing Permits

MFD Permit Type	Issue Date	Expiration Date
Self Service	5/15/2023	12/31/2025

Owner Summary

Click for Facility/Tank Ownership history

Owner Number	Owner Name	Owner Status	Purchase Date
U0029973	Sam's West, Inc.	Current Owner
U0031786	DO NOT USE THIS NUMBER, former SamsEast	Former Owner

Permits (Unexpired)

Click for permit history

No Active Permits Found

Deficiencies (Current)

No Deficiencies Found

IEMA Numbers Associated with the Facility

No IEMA Numbers Found

LUST Fund Eligibility and Deductibility Determinations

No Applications Found

Pay Tank Fees Online

Tank Information

Tank Number 1

Capacity:	20000		Petroleum Use:
Product:	Gasoline - Regular		CERCLA Substance:
Status:	Currently in use		CAS Code:
Regulated Status:	Federal		Removed Date:
OSFM First Notify Date:	5/28/2004		Abandoned Material:
Current Age:	20		Abandoned Date:
Install Date:	4/21/2004		Red Tag Issue Date:
Last Used Date:			Fee Due:	$0.00
Product Date:

Equipment

Equipment Type	Equipment	Last Passing Date	Test Expire Date
Corrosion Prot - Piping	Flexible Non-Corrosive	N/A	N/A
Corrosion Prot - Tank	Fiberglass Non-Corrosive	N/A	N/A
Leak Detect - Piping	Mechanical Pressurized Line Leak Detection	6/1/2023	6/1/2024
Leak Detect - Tank	Non-Discriminating Interstitial Monitoring Sensors With Monitor	6/1/2023	6/1/2024
Overfill Prev Device	Overfill Drop Tube Valve	6/23/2022	6/23/2025
Piping	Flexible Double Wall OPW Pisces	N/A	N/A
Piping	Single Wall STP/Tanktop Sump	6/16/2021	6/16/2024
Leak Detect - Piping	Sump Sensor	6/1/2023	6/1/2024
Spill Contain Device	Double Wall Spill Bucket	6/1/2023	6/1/2026
Tank	Fiberglass Double Wall	N/A	N/A

Additional Tests

Equipment Type	Equipment	Test Type	Test Result	Test Date
Piping	Flexible Double Wall OPW Pisces	Precision Test	Pass	6/1/2023
Tank	Fiberglass Double Wall	Precision Test (Tank)	Pass	6/1/2023

Tank Number 2

Capacity:	20000		Petroleum Use:
Product:	Gasoline - Regular		CERCLA Substance:
Status:	Currently in use		CAS Code:
Regulated Status:	Federal		Removed Date:
OSFM First Notify Date:	5/28/2004		Abandoned Material:
Current Age:	20		Abandoned Date:
Install Date:	4/21/2004		Red Tag Issue Date:
Last Used Date:			Fee Due:	$0.00
Product Date:

Equipment

Equipment Type	Equipment	Last Passing Date	Test Expire Date
Corrosion Prot - Piping	Flexible Non-Corrosive	N/A	N/A
Corrosion Prot - Tank	Fiberglass Non-Corrosive	N/A	N/A
Leak Detect - Piping	Mechanical Pressurized Line Leak Detection	6/16/2023	6/16/2024
Leak Detect - Tank	Non-Discriminating Interstitial Monitoring Sensors With Monitor	6/1/2023	6/1/2024
Overfill Prev Device	Overfill Drop Tube Valve	6/23/2022	6/23/2025
Piping	Flexible Double Wall OPW Pisces	N/A	N/A
Piping	Single Wall STP/Tanktop Sump	6/16/2021	6/16/2024
Leak Detect - Piping	Sump Sensor	6/1/2023	6/1/2024
Spill Contain Device	Double Wall Spill Bucket	6/1/2023	6/1/2026
Tank	Fiberglass Double Wall	N/A	N/A

Additional Tests

Equipment Type	Equipment	Test Type	Test Result	Test Date
Piping	Flexible Double Wall OPW Pisces	Precision Test	Pass	6/1/2023
Tank	Fiberglass Double Wall	Precision Test (Tank)	Pass	6/1/2023

Tank Number 3

Capacity:	20000		Petroleum Use:
Product:	Gasoline - Premium		CERCLA Substance:
Status:	Currently in use		CAS Code:
Regulated Status:	Federal		Removed Date:
OSFM First Notify Date:	5/28/2004		Abandoned Material:
Current Age:	20		Abandoned Date:
Install Date:	4/21/2004		Red Tag Issue Date:
Last Used Date:			Fee Due:	$0.00
Product Date:

Equipment

Equipment Type	Equipment	Last Passing Date	Test Expire Date
Corrosion Prot - Piping	Flexible Non-Corrosive	N/A	N/A
Corrosion Prot - Tank	Fiberglass Non-Corrosive	N/A	N/A
Leak Detect - Piping	Mechanical Pressurized Line Leak Detection	6/1/2023	6/1/2024
Leak Detect - Tank	Non-Discriminating Interstitial Monitoring Sensors With Monitor	6/1/2023	6/1/2024
Overfill Prev Device	Overfill Drop Tube Valve	6/23/2022	6/23/2025
Piping	Flexible Double Wall OPW Pisces	N/A	N/A
Piping	Single Wall STP/Tanktop Sump	6/16/2021	6/16/2024
Leak Detect - Piping	Sump Sensor	6/1/2023	6/1/2024
Spill Contain Device	Double Wall Spill Bucket	6/1/2023	6/1/2026
Tank	Fiberglass Double Wall	N/A	N/A

Additional Tests

Equipment Type	Equipment	Test Type	Test Result	Test Date
Piping	Flexible Double Wall OPW Pisces	Precision Test	Pass	6/1/2023
Tank	Fiberglass Double Wall	Precision Test (Tank)	Pass	6/1/2023

Dispenser Information

Name\ID 1/2

Status:	Active

Equipment Type	Equipment	Last Passing Date	Test Expire Date
Dispenser	Single Wall UDC Sump	8/2/2021	8/2/2024
Leak Detect - Piping	Sump Sensor	6/1/2023	6/1/2024

Name\ID 11/12

Status:	Active

Equipment Type	Equipment	Last Passing Date	Test Expire Date
Dispenser	Single Wall UDC Sump	8/2/2021	8/2/2024
Leak Detect - Piping	Sump Sensor	6/1/2023	6/1/2024

Name\ID 3/4

Status:	Active

Equipment Type	Equipment	Last Passing Date	Test Expire Date
Dispenser	Single Wall UDC Sump	8/2/2021	8/2/2024
Leak Detect - Piping	Sump Sensor	6/1/2023	6/1/2024

Name\ID 5/6

Status:	Active

Equipment Type	Equipment	Last Passing Date	Test Expire Date
Dispenser	Single Wall UDC Sump	8/2/2021	8/2/2024
Leak Detect - Piping	Sump Sensor	6/1/2023	6/1/2024

Name\ID 7/8

Status:	Active

Equipment Type	Equipment	Last Passing Date	Test Expire Date
Dispenser	Single Wall UDC Sump	8/2/2021	8/2/2024
Leak Detect - Piping	Sump Sensor	6/1/2023	6/1/2024

Name\ID 9/10

Status:	Active

Equipment Type	Equipment	Last Passing Date	Test Expire Date
Dispenser	Single Wall UDC Sump	8/2/2021	8/2/2024
Leak Detect - Piping	Sump Sensor	6/1/2023	6/1/2024

MFD Motorfuel Dispensing Forms

No Forms Found