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City of Santa P na <br />Clerk of the Coii <br />AGREEMENT TERMINATION FORM <pj <br />Please complete this form in its entirety when the attached agreement and all <br />amendments (if any) are no longer in effect. <br />Note: If your agreement is grant related, please ensure that all grant retention requirements <br />have been satisfied prior to signing the termination form. /<< <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 />A-2019-094-0,) 1l r7 Z <br />No. was completed on <br />(List all amendments. Use space below if needed.) nn <br />Department: CII� <br />=7i0jel C)qk- OS YJ <br />Revised: 10-18-16 <br />COTC Office Use Only <br />OF THE 10GJNusi- <br />2 '23 P144:25 <br />and final payment has been made. <br />Phone/Ext.: t%J� <br />Signature: <br />Date: (ILI 1 77- <br />3> <br />