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City of Santa Ana <br />1� Clerk of the Council COTC Off Ice Use Only <br />AGREEMENT TERMINATION FORM <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amendments (if any) are no longer in effect.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 _ ;-s Tt 7 OK iijrN _ <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 t'E 1 Qf , ck M <br />No. 40��9 a was completed on tq 31 I 109.A and final payment has been made. <br />(List all amendments. Use space below if needed.) <br />Department: MrA <br />Phone/Ext.: rnTjek <br />Signature: Kf L___,_ <br />Date: 16 1 \a 1 2A2 t <br />Revised: 10-18-16 <br />