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Date: 1 <br /> Revised:10-18-16 <br /> City of Santa Ana <br /> t Clerk of the Council COTc Office use only <br /> AGREEMENT TERMINATION FORM t119 NI 17 ( r 75 <br /> Please complete this form in its entirety when the attached agreement and all OSP TA <br /> amendments (if any) are no longer in effect. <br /> r �Q�t{ �, <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 0C- Soc,ic-` Send: tea Age., , <br /> No. A 2 01- - l Ste was completed on Co I 30`2a10and final payment has been made. <br /> (List all amendments. Use space below if needed.) <br /> Department: C b Of (W o2.tC- Cent <br /> Phone/Ext.: X Zlf+2-Q[ <br /> Signature: or-(os de tc l�uo, <br /> Date: 7 -- ILA - 201i <br /> Revised:10-18-16 <br />