Information
JB Pritzker, Governor

James A. Rivera, State Fire Marshal

Division of Petroleum & Chemical Safety
State of Illinois
Employment Opportunities
Ready Illinois
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Division of Petroleum & Chemical Safety

 

Facility Details

Facility Number: 6045293
Status: Active
Facility Name: Sam's Club #4878
Address: 5 Illini Drive
Glen Carbon, IL 62034
County: Madison
Property Parcel: 14-2-15-23-04-401-016
Facility Type: Attended Self-Service Station
Owner Type: Private
Green Tag Decal: Y001975
Green Tag Issue Date: 9/1/2023
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: 3/26/2013
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 9/1/2023 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 3/26/2013
U0036780 Sam's West Inc. Former Owner 3/26/2013

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: 9/6/2013 Abandoned Material:
Current Age: 11 Abandoned Date:
Install Date: 3/26/2013 Red Tag Issue Date:
Last Used Date: Fee Due: $0.00
Product Date: 3/26/2013

Equipment

Equipment Type Equipment Last Passing Date Test Expire Date
Corrosion Prot - Piping Fiberglass Non-Corrosive N/A N/A
Corrosion Prot - Tank Fiberglass Non-Corrosive N/A N/A
Leak Detect - Piping Mechanical Pressurized Line Leak Detection 11/29/2023 11/29/2024
Leak Detect - Tank Automatic Tank Gauging Veeder Root TLS 450 Plus with CSLD 11/29/2023 11/29/2024
Leak Detect - Tank Non-Discriminating Interstitial Monitoring Sensors 11/29/2023 11/29/2024
Overfill Prev Device Overfill Drop Tube Valve 11/29/2023 11/29/2026
Piping Polyethylene Chase N/A N/A
Piping Flexible Double Wall OPW Flexworks N/A N/A
Piping Single Wall STP/Tanktop Sump 8/31/2021 8/31/2024
Leak Detect - Piping Sump Sensor with positive shutdown 11/29/2023 11/29/2024
Spill Contain Device Double Wall Spill Bucket 11/29/2023 11/29/2026
Tank Fiberglass Double Wall XERXES N/A N/A

Additional Tests

Equipment Type Equipment Test Type Test Result Test Date
Piping Flexible Double Wall OPW Flexworks Precision Test Pass 11/29/2023
Tank Fiberglass Double Wall XERXES Precision Test (Tank) Pass 2/28/2023



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: 9/6/2013 Abandoned Material:
Current Age: 11 Abandoned Date:
Install Date: 3/26/2013 Red Tag Issue Date:
Last Used Date: Fee Due: $0.00
Product Date: 3/26/2013

Equipment

Equipment Type Equipment Last Passing Date Test Expire Date
Corrosion Prot - Piping Fiberglass Non-Corrosive N/A N/A
Corrosion Prot - Tank Fiberglass Non-Corrosive N/A N/A
Leak Detect - Piping Mechanical Pressurized Line Leak Detection 11/29/2023 11/29/2024
Leak Detect - Tank Automatic Tank Gauging Veeder Root TLS 450 Plus with CSLD 11/29/2023 11/29/2024
Leak Detect - Tank Non-Discriminating Interstitial Monitoring Sensors 11/29/2023 11/29/2024
Overfill Prev Device Overfill Drop Tube Valve 11/29/2023 11/29/2026
Piping Polyethylene Chase N/A N/A
Piping Flexible Double Wall OPW Flexworks N/A N/A
Piping Single Wall STP/Tanktop Sump 8/31/2021 8/31/2024
Leak Detect - Piping Sump Sensor with positive shutdown 11/29/2023 11/29/2024
Spill Contain Device Double Wall Spill Bucket 11/29/2023 11/29/2026
Tank Fiberglass Double Wall XERXES N/A N/A

Additional Tests

Equipment Type Equipment Test Type Test Result Test Date
Piping Flexible Double Wall OPW Flexworks Precision Test Pass 11/29/2023
Tank Fiberglass Double Wall XERXES Precision Test (Tank) Pass 2/28/2023



Tank Number 3

Capacity: 12000 Petroleum Use:
Product: Gasoline - Premium CERCLA Substance:
Status: Currently in use CAS Code:
Regulated Status: Federal Removed Date:
OSFM First Notify Date: 9/6/2013 Abandoned Material:
Current Age: 11 Abandoned Date:
Install Date: 3/26/2013 Red Tag Issue Date:
Last Used Date: Fee Due: $0.00
Product Date: 3/26/2013

Equipment

Equipment Type Equipment Last Passing Date Test Expire Date
Corrosion Prot - Piping Fiberglass Non-Corrosive N/A N/A
Corrosion Prot - Tank Fiberglass Non-Corrosive N/A N/A
Leak Detect - Piping Mechanical Pressurized Line Leak Detection 11/29/2023 11/29/2024
Leak Detect - Tank Automatic Tank Gauging Veeder Root TLS 450 Plus with CSLD 11/29/2023 11/29/2024
Leak Detect - Tank Non-Discriminating Interstitial Monitoring Sensors 11/29/2023 11/29/2024
Overfill Prev Device Overfill Drop Tube Valve 11/29/2023 11/29/2026
Piping Polyethylene Chase N/A N/A
Piping Flexible Double Wall OPW Flexworks N/A N/A
Piping Single Wall STP/Tanktop Sump 8/31/2021 8/31/2024
Leak Detect - Piping Sump Sensor with positive shutdown 11/29/2023 11/29/2024
Spill Contain Device Double Wall Spill Bucket 11/29/2023 11/29/2026
Tank Fiberglass Double Wall XERXES N/A N/A

Additional Tests

Equipment Type Equipment Test Type Test Result Test Date
Piping Flexible Double Wall OPW Flexworks Precision Test Pass 11/29/2023
Tank Fiberglass Double Wall XERXES Precision Test (Tank) Pass 2/28/2023



Tank Number 4

Capacity: 8000 Petroleum Use:
Product: Diesel Fuel CERCLA Substance:
Status: Currently in use CAS Code:
Regulated Status: Federal Removed Date:
OSFM First Notify Date: 9/6/2013 Abandoned Material:
Current Age: 11 Abandoned Date:
Install Date: 3/26/2013 Red Tag Issue Date:
Last Used Date: Fee Due: $0.00
Product Date: 3/26/2013

Equipment

Equipment Type Equipment Last Passing Date Test Expire Date
Corrosion Prot - Piping Fiberglass Non-Corrosive N/A N/A
Corrosion Prot - Tank Fiberglass Non-Corrosive N/A N/A
Leak Detect - Piping Mechanical Pressurized Line Leak Detection 11/29/2023 11/29/2024
Leak Detect - Tank Automatic Tank Gauging Veeder Root TLS 450 Plus with CSLD 11/29/2023 11/29/2024
Leak Detect - Tank Non-Discriminating Interstitial Monitoring Sensors 11/29/2023 11/29/2024
Overfill Prev Device Overfill Drop Tube Valve 11/29/2023 11/29/2026
Piping Polyethylene Chase N/A N/A
Piping Flexible Double Wall OPW Flexworks N/A N/A
Piping Single Wall STP/Tanktop Sump 8/31/2021 8/31/2024
Leak Detect - Piping Sump Sensor with positive shutdown 11/29/2023 11/29/2024
Spill Contain Device Double Wall Spill Bucket 11/29/2023 11/29/2026
Tank Fiberglass Double Wall XERXES N/A N/A

Additional Tests

Equipment Type Equipment Test Type Test Result Test Date
Piping Flexible Double Wall OPW Flexworks Precision Test Pass 11/29/2023
Tank Fiberglass Double Wall XERXES Precision Test (Tank) Pass 2/28/2023

Dispenser Information



Name\ID 1/2

Status: Active
Equipment Type Equipment Last Passing Date Test Expire Date
Dispenser Single Wall UDC Sump 8/31/2021 8/31/2024
Leak Detect - Piping Sump Sensor with positive shutdown 11/29/2023 11/29/2024



Name\ID 11/12

Status: Active
Equipment Type Equipment Last Passing Date Test Expire Date
Dispenser Single Wall UDC Sump 8/31/2021 8/31/2024
Leak Detect - Piping Sump Sensor with positive shutdown 11/29/2023 11/29/2024



Name\ID 3/4

Status: Active
Equipment Type Equipment Last Passing Date Test Expire Date
Dispenser Single Wall UDC Sump 8/31/2021 8/31/2024
Leak Detect - Piping Sump Sensor with positive shutdown 11/29/2023 11/29/2024



Name\ID 5/6

Status: Active
Equipment Type Equipment Last Passing Date Test Expire Date
Dispenser Single Wall UDC Sump 8/31/2021 8/31/2024
Leak Detect - Piping Sump Sensor with positive shutdown 11/29/2023 11/29/2024



Name\ID 7/8

Status: Active
Equipment Type Equipment Last Passing Date Test Expire Date
Dispenser Single Wall UDC Sump 8/31/2021 8/31/2024
Leak Detect - Piping Sump Sensor with positive shutdown 11/29/2023 11/29/2024



Name\ID 9/10

Status: Active
Equipment Type Equipment Last Passing Date Test Expire Date
Dispenser Single Wall UDC Sump 8/31/2021 8/31/2024
Leak Detect - Piping Sump Sensor with positive shutdown 11/29/2023 11/29/2024

MFD Motorfuel Dispensing Forms

No Forms Found

Office of the Illinois State Fire Marshal
1035 Stevenson Dr. Springfield, IL 62704 | (217) 785-0969 | Contact Us