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MnWARN <br />Minnesota's Water/Wastewater <br />Agency Response Network <br />Member Information Form <br />Utility Information <br />Utility Name: <br />Fill-in applicable information: <br />Water Utility: ❑ <br />PWS ID#: <br />Connections: <br />Type of System: <br />❑ Groundwater OR <br />❑ Source Water <br />Wastewater Utility: ❑ <br />Permit# <br />Connections: <br />Storm Water Utility: ❑ <br />Permit# (if applicable) <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 />