MassDOT ROE 1 of 1
REV 1/2010
ENVIRONMENTAL SERVICES
RIGHT OF ENTRY
I/We, ______________________________, the sole owners(s) of property located at
___________________________________, Massachusetts (“Property”), do hereby grant
permission to the Massachusetts Department of Transportation (MassDOT), Highway Division
and its duly authorized agents and contractors to enter upon the Property for the purpose of
collecting water samples and pertinent data related to the water supply well and plumbing
system to evaluate the impact of highway deicing salt use on the water supply. These samples
will be collected on a monthly basis for a sufficient length of time to make a determination
based on the results of the water analyses. All costs connected with the above described work
shall be born by MassDOT, Highway Division.
*Signed this _________________________ day of _________________________________,
20_____
Signatures of Property Owner(s) ____________________________
___________________________
____________________________ ___________________________
(Print Name) (Print Name)
COMMONWEALTH OF MASSACHUSETTS
_______________ _____________________________
County City/Town State
On this ____ day of _____, 20____, before me, the undersigned notary public, personally
appeared _________________________, proved to me through satisfactory evidence of
identification, which were _________________________, to be the person whose name is
signed on the preceding or attached document and acknowledged to me that he/she signed
it voluntarily for its stated purpose.
Before me,
____________________________
Notary Public
My commission expires:
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