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City of San' Ana <br />Clerk of the (. ouncil <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amendments (if any) are no longer in effect.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 />Mote: 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 Councii Office (M-30) . <br />Call 647-1520 if you have any questions. <br />The agreement with Lu ~t' , <br />A-2021-107-01 <br />No. <br />(List all amendments. <br />0 <br />was completed on <br />Use space below if needed.) <br />Department: <br />Phone/Ext.: <br />Signature: <br />Date: <br />iAagreemenisVormMform - agreement termination form—goldenrod.doc <br />COTC office Use onl <br />C2-0 2-3 <br />ow of Santa ""I" <br />CIce <br />n, <br />and final payment has been made. <br />