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01 <br />City of Santa Ana <br />City Clerk <br />fbikJAV <br />AGREEMENT TERMINATION FORM <br />Please complete this form in its entirety when the attached agreement and al <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amendments (if any) are no longer in effect.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 City Clerk's Office (M-30) . <br />Call 647-6520 if you have any questions. <br />COTC Office Use Only <br />C 2,(DL27:� <br />City of Santa Ana <br />JAN 112024 <br />City Cleric's Office <br />The agreement with I tvyi A+mv-dL, <br />0 tt C <br />No. -�Gb r ,' —� was completed on 3c)[72 and final payment has been made. <br />(List all amendments. Use space below if needed.) <br />iAagreementslrormslform - agreement termination form_goldenrod.doc <br />Department: ��J A- <br />Phone/Ext.: 24 -1 <br />Signature: SO) T <br />Date: IM2.3 <br />