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City of Santa Ana <br />t Clerk of the Council aoTC office use only <br />AGREEMENT TERMINATION FORM <br />Please complete this farm in its entirety when the attached agreement and all <br />amendments (if any) are no longer in elfect. 7" BEC 12. All % 50 <br />Note: If your agreement is grant related, please ensure that all grant retention requirements <br />hate been satisfied prior to signing the termination form. C} Y 0! SnH 1A ANA <br />Is the agreement(s) a permanent record? Yes No <br />Return form to the Clerk of the Council Office (M-30). <br />Call 647-1520 if you have any questions <br />The agreement with <br />No. A -',-t6('�- - 3� was completed on ld ( / and final payment has been made. <br />(List all amendments. Use space below if needed.) /� / _ y( <br />/ Department: Gyy� Phone/Ext.: � �3 <br />Signature: <br />Date: <br />Re.,satl: 10-13-16 <br />