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Member Information Form <br />Utility Information <br />Utility Name: _________________________________________________________ <br />Fill-in applicable information: <br /> <br />Water Utility: Wastewater Utility: Storm Water Utility: <br /> <br />PWS ID#: Permit# Permit# (if applicable) <br />________________ __________________ <br />Connections: Connections: <br />___________________________ <br />_____________ _____________ <br />Type of System: <br /> <br />Groundwater OR <br /> <br />Source Water <br />Physical Address: ______________________________________________________ <br />City/State/Zip:________________________________________________________ <br />County: _________________________________________________________ <br />24 Hour Telephone#____________________________________________________ <br />Authorized Official: Primary Contact Information <br />Name: _________________________________________________________ <br />Title: _________________________________________________________ <br />Emergency Telephone#:_________________________________________________ <br />E-mail: _________________________________________________________ <br />Additional Personnel Contact Information <br />Name: _________________________________________________________ <br />Title <br />Emergency Telephone#:_________________________________________________ <br />E-mail: _________________________________________________________ <br />Emergency Operation Center: <br />Name: _________________________________________________________ <br />Emergency Telephone#:_________________________________________________ <br />E-mail: _________________________________________________________ <br />Return Completed Form to MnWARN at 217 12th Avenue SE, Elbow Lake, MN 56531 <br /> <br />