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City of Santa - na I <br />t Clerk of the Council I <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amendments (if any) are no longer in effect.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 <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 />COTC Office Use Only <br />OF THE COUNCIL <br />' 23'22 AlI9:230 <br />bov P►'kn� iwoll <br />N-2021-241 <br />No. was completed on and final payment has been made. <br />(List aN amendments. Use space below N needed.) <br />ilagreementsUorms\form- agreement termination form_goldenrod.doc <br />Department: 3P—LSA— <br />Phone/Ext <br />X 5z",5;)- <br />Signature:✓{ <br />Date: <br />