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City of Santa Ana <br />Clerk of the Council <br />AGREEMENT TERMINATION FORM <br />Please complete this form in its entirety when the attached agree rpWd6ll <br />amendments (if any) are no longer in effect. <br />Note: If your agreement is grant related, please ensure that all grant retention requireQRW 0 r $ A', <br />have been satisfied prior to signing the termination form. CL E H OF <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 />4: 22 <br />A ANA <br />UNCIL <br />i <br />No. was completed on and final payment has been made. <br />(List all amendments. Use space below N needed.) <br />Department: PRCSA <br />Phone/Ext.: 40A <br />Signature: <br />Date: q �2y I� 1d1 <br />Revised: 10-18-16 <br />