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City of Santa A n- a �f <br />Clerk of the Coo,_ A CorC office use only <br />- --- - -— <br />AGREEMENT TERMINATION FORM <br />41"111"! 17 FIM <br />Please complete this form when the attached agreement and all <br />amendments (if any) are no longer in effect. l QTY 0 1 'A 1z'A HT E s <br />CLERK 0' <br />Return form to the Clerk of the Council Office (M -30). <br />Call 647 -6520 if you have any questions. <br />The agreement with <br />No. N-2012-123 was completed on -3V -I L( and final payment has been made. <br />(List all amendments. Use space below if needed) <br />Department: rFb.1'fy <br />Phone /Ext.: �5-3 7 <br />Signature: <br />Date:° �L 2915 <br />Revised 0 8-2 3-10 <br />