Information

JB Pritzker, Governor

James A. Rivera, State Fire Marshal

Division of Petroleum & Chemical Safety

State of Illinois
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Division of Petroleum & Chemical Safety

Facility Details

Facility Number:	2030399
Status:	Active
Facility Name:	Sam's Club #6358
Address:	141 West North Ave. Northlake, IL 60164
County:	Cook
Property Parcel:	15-06-201-060-0000
Facility Type:	Attended Self-Service Station
Owner Type:	Private
Green Tag Decal:	Z000030
Green Tag Issue Date:	4/19/2024
Green Tag Expiration Date:	12/31/2026

Owner Details

Owner Name:	Sam's West, Inc.
Owner Address:	2101 SE Simple Savings Drive Bentonville, AR 727160745
Owner Status:	Current Owner
Purchase Date:	3/14/2002
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	4/19/2024	12/31/2026

Owner Summary

Click for Facility/Tank Ownership history

Owner Number	Owner Name	Owner Status	Purchase Date
U0029973	Sam's West, Inc.	Current Owner	3/14/2002
U0019919	DO NOT USE THIS NUMBER, former Wal-mart	Former Owner	4/11/1999

Permits (Unexpired)

Click for permit history

No Active Permits Found

Notice of Violations (Current)

No Notice of Violations Found

IEMA Numbers Associated with the Facility

IEMA Number	Inspection Date	Inspection Type	Permit Number
92-1640	7/28/1992	Removal Log

LUST Fund Eligibility and Deductibility Determinations

No Applications Found

Pay Tank Fees Online

Tank Information

Tank Number 1

Capacity:	5000		Petroleum Use:	Consumptive Use on Premises for Heating
Product:	Heating Oil		CERCLA Substance:
Status:	Removed		CAS Code:
Regulated Status:	State		Removed Date:	7/28/1992
OSFM First Notify Date:	6/23/1992		Abandoned Material:
Current Age:			Abandoned Date:
Install Date:			Red Tag Issue Date:
Last Used Date:	6/1/1988		Fee Due:	$0.00
Product Date:

Equipment

Equipment Type	Equipment	Last Passing Date	Test Expire Date

Additional Tests

Equipment Type	Equipment	Test Type	Test Result	Test Date

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:	4/9/2002		Abandoned Material:
Current Age:	23		Abandoned Date:
Install Date:	3/14/2002		Red Tag Issue Date:
Last Used Date:			Fee Due:	$0.00
Product Date:	3/14/2002

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	12/5/2024	12/5/2025
Leak Detect - Piping	Siphon Bar	N/A	N/A
Leak Detect - Tank	Automatic Tank Gauging Veeder Root TLS 450 Plus with CSLD	12/5/2024	12/5/2025
Leak Detect - Tank	Non-Discriminating Interstitial Monitoring Sensors	12/5/2024	12/5/2025
Overfill Prev Device	Overfill Drop Tube Valve	1/24/2023	1/24/2026
Piping	Flexible Double Wall OPW Pisces	N/A	N/A
Piping	Single Wall STP/Tanktop Sump	8/19/2024	8/19/2027
Leak Detect - Piping	Non-Discriminating Sump Sensor	3/12/2019	3/12/2020
Leak Detect - Piping	Piping Sump Sensors Not Regulated	N/A	N/A
Leak Detect - Piping	Piping Sump Sensors Not Regulated Not Installed	N/A	N/A
Spill Contain Device	Double Wall Spill Bucket	12/5/2024	12/5/2027
Tank	Fiberglass Double Wall XERXES	N/A	N/A

Additional Tests

Equipment Type	Equipment	Test Type	Test Result	Test Date
Leak Detect - Piping	Siphon Bar	Functional	Pass	1/24/2023
Piping	Flexible Double Wall OPW Pisces	Precision Test (Piping)	Pass	12/5/2024
Tank	Fiberglass Double Wall XERXES	Precision Test (Tank)	Pass	2/9/2021

Tank Number 3

Capacity:	20000		Petroleum Use:
Product:	Gasoline - Regular		CERCLA Substance:
Status:	Currently in use		CAS Code:
Regulated Status:	Federal		Removed Date:
OSFM First Notify Date:	4/9/2002		Abandoned Material:
Current Age:	23		Abandoned Date:
Install Date:	3/14/2002		Red Tag Issue Date:
Last Used Date:			Fee Due:	$0.00
Product Date:	3/14/2002

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	12/5/2024	12/5/2025
Leak Detect - Piping	Siphon Bar	N/A	N/A
Leak Detect - Tank	Automatic Tank Gauging Veeder Root TLS 450 Plus with CSLD	12/16/2024	12/16/2025
Leak Detect - Tank	Non-Discriminating Interstitial Monitoring Sensors	12/5/2024	12/5/2025
Overfill Prev Device	Overfill Drop Tube Valve	1/24/2023	1/24/2026
Piping	Flexible Double Wall OPW Pisces	N/A	N/A
Piping	Single Wall STP/Tanktop Sump	8/19/2024	8/19/2027
Leak Detect - Piping	Non-Discriminating Sump Sensor	3/3/2020	3/3/2021
Leak Detect - Piping	Piping Sump Sensors Not Regulated	N/A	N/A
Leak Detect - Piping	Piping Sump Sensors Not Regulated Not Installed	N/A	N/A
Spill Contain Device	Double Wall Spill Bucket	12/5/2024	12/5/2027
Tank	Fiberglass Double Wall XERXES	N/A	N/A

Additional Tests

Equipment Type	Equipment	Test Type	Test Result	Test Date
Leak Detect - Piping	Siphon Bar	Functional	Pass	1/24/2023
Piping	Flexible Double Wall OPW Pisces	Precision Test (Piping)	Pass	12/5/2024
Tank	Fiberglass Double Wall XERXES	Precision Test (Tank)	Pass	2/9/2021

Tank Number 4

Capacity:	20000		Petroleum Use:
Product:	Gasoline - Premium		CERCLA Substance:
Status:	Currently in use		CAS Code:
Regulated Status:	Federal		Removed Date:
OSFM First Notify Date:	4/9/2002		Abandoned Material:
Current Age:	23		Abandoned Date:
Install Date:	3/14/2002		Red Tag Issue Date:
Last Used Date:			Fee Due:	$0.00
Product Date:	3/14/2002

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	12/5/2024	12/5/2025
Leak Detect - Tank	Automatic Tank Gauging Veeder Root TLS 450 Plus with CSLD	12/5/2024	12/5/2025
Leak Detect - Tank	Non-Discriminating Interstitial Monitoring Sensors	12/5/2024	12/5/2025
Overfill Prev Device	Overfill Drop Tube Valve	2/10/2023	2/10/2026
Piping	Flexible Double Wall OPW Pisces	N/A	N/A
Piping	Single Wall STP/Tanktop Sump	8/19/2024	8/19/2027
Leak Detect - Piping	Non-Discriminating Sump Sensor	3/3/2020	3/3/2021
Leak Detect - Piping	Piping Sump Sensors Not Regulated	N/A	N/A
Leak Detect - Piping	Piping Sump Sensors Not Regulated Not Installed	N/A	N/A
Spill Contain Device	Double Wall Spill Bucket	12/5/2024	12/5/2027
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 Pisces	Precision Test (Piping)	Pass	12/5/2024
Tank	Fiberglass Double Wall XERXES	Precision Test (Tank)	Pass	2/9/2021

Dispenser Information

Name\ID 1/2

Status:	Active

Equipment Type	Equipment	Last Passing Date	Test Expire Date
Dispenser	Single Wall UDC Sump
Leak Detect - Piping	Piping Sump Sensors Not Regulated Not Installed	N/A	N/A

Name\ID 11/12

Status:	Active

Equipment Type	Equipment	Last Passing Date	Test Expire Date
Dispenser	Single Wall UDC Sump
Leak Detect - Piping	Piping Sump Sensors Not Regulated Not Installed	N/A	N/A

Name\ID 3/4

Status:	Active

Equipment Type	Equipment	Last Passing Date	Test Expire Date
Dispenser	Single Wall UDC Sump
Leak Detect - Piping	Piping Sump Sensors Not Regulated Not Installed	N/A	N/A

Name\ID 5/6

Status:	Active

Equipment Type	Equipment	Last Passing Date	Test Expire Date
Dispenser	Single Wall UDC Sump
Leak Detect - Piping	Piping Sump Sensors Not Regulated Not Installed	N/A	N/A

Name\ID 7/8

Status:	Active

Equipment Type	Equipment	Last Passing Date	Test Expire Date
Dispenser	Single Wall UDC Sump
Leak Detect - Piping	Piping Sump Sensors Not Regulated Not Installed	N/A	N/A

Name\ID 9/10

Status:	Active

Equipment Type	Equipment	Last Passing Date	Test Expire Date
Dispenser	Single Wall UDC Sump
Leak Detect - Piping	Piping Sump Sensors Not Regulated Not Installed	N/A	N/A

MFD Motorfuel Dispensing Forms

No Forms Found